Depression
and Depressive Symptoms in Smoking Cessation
Lirio S. Covey, Alexander H. Classman, and Fay Stetner Previous findings from a smoking cessation trial showed that smokers with a history of major depression had lower success rates than smokers without a depression history. In an attempt to explain the worse outcome observed for smokers with a history of depression, postcessation data obtained from subjects randomly assigned to the placebo condition were examined further. It was observed that in the first week of a behaviorally oriented treatment program, the frequency and intensity of psychological symptoms, particularly depressive mood, were higher among smokers with past depression, and that this discomfort was related to treatment outcome. Interventions designed to prevent dysphoric symptoms during the acute withdrawal period may improve smoking cessation outcome for smokers with a history of major depression. 0 1990 by W. B. Saunders Company.
B
ETWEEN 1965 AND 1987, the prevalence of cigarette smoking among adult Americans declined from 40% to 29%’ Close to half of all persons who ever smoked have quit.’ However, the proportion of heavy smokers among those who continue to smoke, as well as the proportion among them who made attempts to quit, has risen.’ Thus, it appears that although the overall rate of current smokers in the general population has decreased, the proportion of addicted smokers, i.e., heavy cigarette smokers unable to stop smoking on their own, has actually increased. It may be that for this group, more specialized interventions than have been applied in the past are needed. Epidemiological, psychological, and psychiatric information could provide useful clues for the development of more efficacious smoking cessation strategies for refractory smokers. Although much is known about the characteristics of smokers and exsmokers in general, such knowledge relating particularly to the addicted smoker is limited. Smoking researchers have not customarily disaggregated that subgroup of smokers who have attempted but failed to stop smoking from current smokers who have never tried to quit, or from smokers who are able to stop at their first attempt. Recently, we reported results from a clinical trial of clonidine for smoking cessation that involved heavy smokers, all of whom had failed in previous attempts to quit3 In the course of this study, we made two unexpected observations: there was an unusually high prevalence of past major depression (61%) in our sample, and this past history predicted a poor response to treatment whether the subject received the active drug or placebo. Findings from other studies suggest that the first observation was not spurious. A study of psychiatric outpatients found cigarette smoking to be more common among patients with major depression than among a community sample representative of the general population.4 In addition, a survey of 1,004 children aged 15 to 16 years indicated that depressive symptoms at this early age From the Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY. Address reprint requests to Lirio S. Covey, Ph.D., Columbia University. Box 116, 722 W 168th St, New York, NY 10032. 0 1990 by W.B. Saunders Company. 0010-440x/90/3104-0009$03.00/0 350
Comprehensive
Psychiatry,
Vol. 3 1, No. 4 (July/August),
1990: pp 350-354
DEPRESSION AND SMOKING
CESSATION
351
predicted smoking when the same subjects were interviewed 9 years later.5 Furthermore, observations from Epidemiologic Catchment Area (ECA) data indicate a higher rate of lifetime major depressive disorder among smokers who have tried unsuccessfully to stop smoking compared with never-smokers or smokers who have quit successfully (L. Robbins and J. Helzer, personal communication). However, the second observation that a history of major depressive disorder has a negative influence on the ability to stop smoking is without empirical precedent. Measures of subjects’ postcessation symptoms had been taken in our clonidine trial. We examined these data to determine whether the clinical picture early in the abstinence period could explain the less favorable prognosis for the smoker with a history of depression. We hypothesized that smokers with past depression would experience psychological discomfort during the withdrawal period more severely than would nondepressives; and that such discomfort during acute withdrawal would predict treatment outcome. We were interested both in the effects of an overall symptom measure and in the effects of specific symptoms. This information could be useful in developing specialized interventions for the refractory smoker. METHODS Sample To avoid confounding condition subjects subjects,
effects due to clonidine,
of a double-blind
clonidine
(n = 36) who had completed two dropped
behavioral
treatment
Entry criteria
out before
that subjects
their
smoking
study.
the house in the morning,
Exclusionary
were medical
conditions
drug or alcohol abuse, schizophrenia,
was limited to
38 placebo-assigned
Each
over a 4-week treatment
smokers
to the placebo
Analysis
first week of treatment.)
therapist
be regular
smoke before leaving criteria
who had been randomized
in the present
at least 1 week in the study. (Of the original
completing
from an individual
required
only subjects
trial were included
subject
of 20 or more cigarettes
per day, habitually
and have made at least one previous that might
and current,
increase
received
period. attempt
to quit.
the risk of using clonidine,
current
but not past, major depression.
Data Collection and Measures To measure
a prior history of depression,
and Schizophrenia
(SADS-L),6
trained interviewers. To measure psychological symptoms
experienced
the Lifetime
a semistructured
state early during
during
Version of the Schedule
psychiatric
instrument,
the withdrawal
the first week after a designated
very mild; 2, mild; 3, moderate;
4, severe;
5, extreme)
for Affective Disorders
was administered
period, we obtained
by clinically
subjects’
reports
of
“quit day.” A six-point scale (0, none; 1,
measured
each of these symptoms:
craving,
anxiety, irritability, restlessness, concentration difficulty, appetite increase, and depressive mood. The first six symptoms correspond with the psychological criteria specified in DSM-III-R to comprise nicotine withdrawal.’ We defined symptom
prevalence
intensity
mean values.
by calculating
subject, i.e., total symptom
as a score of 1 or greater We also calculated
count, and obtained
on a 0 to 5 scale and estimated
the total number
the total symptom
across the measured symptoms. Successful outcome at the end of 4 weeks of treatment
intensity
of symptoms
score by summing
was defined by self-reported
symptom
reported
by a
up ratings
abstinence
from
smoking, verified by serum cotinine concentration of less than 15 ng/mL. Subjects who reported smoking or had cotinine measurements in excess of 15 ng/mL by the end of 4 weeks, and dropouts after week 1, were counted as failures. (As stated earlier, two dropouts before week 1 were not included in this analysis since their week 1 data were not available). T tests and chi-square
analyses
were performed
to test the study hypotheses.
352
COVEY, GLASSMAN,
AN0 STETNER
RESULTS
Subjects’ mean age was 34 years (SD = 8.2). They were largely female (69%) and never married (58%). The majority held or were training for professional or managerial occupations (67%); and nearly all had attended college or graduate school (92%). A prior history of major depressive disorder was observed in 56% of the present sample of placebo-assigned subjects. (This proportion is not appreciably different from the figure of 61% previously reported for the overall study sample.) The group’s mean tobacco consumption at baseline was 30 (SD = 10) cigarettes per day. At the end of the 4-week behavioral treatment period, 10 subjects (28%) had quit smoking entirely, while 26 (72%) had not. By the end of week 1, both groups of eventual treatment successes and failures had made substantial reductions in smoking intake. Successes were smoking an average of 2.5 cigarettes per day (SD = 6.2), a reduction of 91% from their baseline smoking level. Eventual treatment failures, on the other hand, were smoking an average of 5.5 cigarettes daily (SD = 5.5), a reduction of 81% from baseline. A comparison of subjects by history of depression on the prevalence of total and individual symptoms during the week following quit day is shown in Table 1. Depressive mood was reported more frequently by past depressives. They also reported a higher symptom count than did nondepressives. Past depressives and their counterparts did not differ in the prevalence of other symptoms. On symptom intensity, smokers with depression history rated depressive mood and concentration difficulty significantly higher than did smokers without past depression. The former also scored higher on the total symptom intensity measure (Table 2). We tested the effect on treatment outcome of our postcessation symptom measures. The week 1 symptom variables that distinguished smokers with past depression from smokers without such a history, i.e., depressive mood, concentration difficulty, total symptom count, and total symptom intensity (Tables 1 and 2), were rated at higher levels by treatment failures (Table 3). Of the other symptoms measured, only craving, which was not related to depression history, showed a significant effect on treatment outcome.
Table 1. Symptom
Prevalence
by History of Depression Historv of Deoression
Present % Individual symptoms Craving Irritability Anxiety Restlessness Appetite increase Difficulty concentrating Depressive mood Symptom count (mean, SD) +x*(Yates) = 5.233, tt = 2.27, P < .03.
P = .02.
100 95 90 85 75 65 75 5.85
Absent
(n) 120) (19) (18) (17) (15) (13) (15) (1.3)
% 100 81 75 81 75 38 31 4.81
(n) (16) (13) (12) (13) (12) (6) (5)* 11.51t
DEPRESSION AND SMOKING
CESSATION
Table 2. Symptom
353
Intensity
by History of Depression
Historv of Deoression Present
Individual symptoms Craving Irritability Anxiety Restlessness Appetite increase Difficulty concentrating Depressive mood Total symptom intensity
Absent
Mean
(SD)
Mean
(SD)
3.40 2.56 2.60 2.40 2.60 1.85 1.85 17.25
(1.1) (1.3) (1.5) (1.4) (1.8) (1.6) (1.4) (7.3)
2.81 2.00 1.75 1.88 2.56 0.81 0.56 12.38
(1.0)
(1.3)
(1.2) (1.3) (1.8) (1.4) (0.9) (5.7)
t 1.63 1.27 1.85 1.14 0.06 2.06t 3.09’ 2.19t
lP< .Ol. tP < .05.
DISCUSSION
Our study sample included a large proportion (56%) of smokers with past major depression. Although this observation corresponds with ECA data showing a higher rate of major depression in smokers who have attempted but failed in cessation attempts compared with nonsmokers or successful quitters, the unusually higher figure we observed may signal that our sample is a highly selected one in terms of psychiatric morbidity. Moreover, their demographic composition, indicating a predominantly middie to upper social class group, and the preponderance of never-married smokers, points to other selection factors. Thus, the generalizability of our findings regarding the effect of postcessation symptoms on outcome to other samples of addicted smokers is open to question. However, our findings may be pertinent for smokers with a past history of depression. Our data showed that this group of smokers experiences more severe symptoms, particularly depressive mood and concentration difficulty, when withdrawing from nicotine than the group without a depression history. Furthermore, these Table 3. Total and Individual Symptom Scores at Week 1 After Quit Day by Treatment Outcome Treatment Outcome Success
Individual symptoms Craving Irritability Anxiety Restlessness Appetite increase Difficulty concentrating Depressive mood Total symptom intensity Total symptom count +P < .Ol.
tP i
.05.
Failure
Mean
(SD)
Mean
(SD)
2.30 2.00 1.60 1.80 3.00 .40 .40 11.50 4.60
(1.1) (1.3) (1.4) (1.1) (1.3) (1.01 (0.4) (5.4) (1.2)
3.46 2.42 2.46 2.31 2.42 1.77 1.61 16.46 5.69
(1.0) 11.3) 11.4) (1.5) (1.9) (1.6) (1.6) (7.1) (1.4)
t 3.191
.87 1.68 .99 .87 2.51t 2.53t 1.99t 2.14t
COVEY, GLASSMAN,
354
AND STETNER
specific symptoms and general psychological discomfort during the abstinent state were associated with a negative treatment outcome. Perhaps, for smokers with past depression, interventions targeted at preventing dysphoric symptoms during withdrawal will increase their chances for successful smoking cessation. The absence of baseline values did not enable us to determine whether the higher level of distress observed immediately upon withdrawal in past depressives represented a change from baseline levels, or merely reflected precessation levels. Thus, it remains to be determined in future work whether the clinical picture we obtained reflects a greater vulnerability to severe nicotine withdrawal on the part of past depressives or a condition of chronic psychological distress. The specific manner in which interventions aimed at preventing depression in nicotine withdrawal should be designed would be guided by such information. As the hazards of cigarette smoking become more widely recognized and the ranks of former smokers continue to grow, the remaining core of current smokers will increasingly include those who are most severely addicted-the heaviest smokers and those least able to stop. The psychiatric profile of this refractory group needs to be defined in epidemiologic studies using representative community samples. Unlike the exsmokers of earlier years, most of whom managed to quit smoking on their own, this group may need specially tailored therapies to break their addiction. The efficacy of symptom-specific interventions should be explored. REFERENCES 1. USDHHS: Reducing the Health Consequences of Smoking. 25 Years of Progress. A Report of the Surgeon General, 1989. Executive Summary. Rockville, MD, Public Health Service, Centers for Disease Control, Office on Smoking and Health 2. USDEW: The Health Consequences of Smoking, Cardiovascular Disease, A Report of the Surgeon General, 1983. Rockville, MD, Public Health Service Publication No. 84-50204 3. Glassman AH, Stetner F, Walsh BT, et al: Heavy smokers, smoking cessation, and clonidine: results of a double-blind, randomized trial. JAMA 259:2863-2866, 1988 4. Hughes JR, Hatsukami DK, Mitchell JE, et al: Prevalence of smoking among psychiatric outpatients. Am J Psychiatry 143:993-997, 1986 5. Kandel DB, Davies M: Adult sequelae of adolescent depressive symptoms. Arch Gen Psychiatry 43~255262, 1986 6. Endicott J, Spitzer RL: A diagnostic interview: The Schedule for Affective Disorders and Schizophrenia. Arch Gen Psychiatry 35:887-844, 1978 7. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3) Revised. Washington, DC, APA, 1987
and Depressive Symptoms in Smoking Cessation
Lirio S. Covey, Alexander H. Classman, and Fay Stetner Previous findings from a smoking cessation trial showed that smokers with a history of major depression had lower success rates than smokers without a depression history. In an attempt to explain the worse outcome observed for smokers with a history of depression, postcessation data obtained from subjects randomly assigned to the placebo condition were examined further. It was observed that in the first week of a behaviorally oriented treatment program, the frequency and intensity of psychological symptoms, particularly depressive mood, were higher among smokers with past depression, and that this discomfort was related to treatment outcome. Interventions designed to prevent dysphoric symptoms during the acute withdrawal period may improve smoking cessation outcome for smokers with a history of major depression. 0 1990 by W. B. Saunders Company.
B
ETWEEN 1965 AND 1987, the prevalence of cigarette smoking among adult Americans declined from 40% to 29%’ Close to half of all persons who ever smoked have quit.’ However, the proportion of heavy smokers among those who continue to smoke, as well as the proportion among them who made attempts to quit, has risen.’ Thus, it appears that although the overall rate of current smokers in the general population has decreased, the proportion of addicted smokers, i.e., heavy cigarette smokers unable to stop smoking on their own, has actually increased. It may be that for this group, more specialized interventions than have been applied in the past are needed. Epidemiological, psychological, and psychiatric information could provide useful clues for the development of more efficacious smoking cessation strategies for refractory smokers. Although much is known about the characteristics of smokers and exsmokers in general, such knowledge relating particularly to the addicted smoker is limited. Smoking researchers have not customarily disaggregated that subgroup of smokers who have attempted but failed to stop smoking from current smokers who have never tried to quit, or from smokers who are able to stop at their first attempt. Recently, we reported results from a clinical trial of clonidine for smoking cessation that involved heavy smokers, all of whom had failed in previous attempts to quit3 In the course of this study, we made two unexpected observations: there was an unusually high prevalence of past major depression (61%) in our sample, and this past history predicted a poor response to treatment whether the subject received the active drug or placebo. Findings from other studies suggest that the first observation was not spurious. A study of psychiatric outpatients found cigarette smoking to be more common among patients with major depression than among a community sample representative of the general population.4 In addition, a survey of 1,004 children aged 15 to 16 years indicated that depressive symptoms at this early age From the Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY. Address reprint requests to Lirio S. Covey, Ph.D., Columbia University. Box 116, 722 W 168th St, New York, NY 10032. 0 1990 by W.B. Saunders Company. 0010-440x/90/3104-0009$03.00/0 350
Comprehensive
Psychiatry,
Vol. 3 1, No. 4 (July/August),
1990: pp 350-354
DEPRESSION AND SMOKING
CESSATION
351
predicted smoking when the same subjects were interviewed 9 years later.5 Furthermore, observations from Epidemiologic Catchment Area (ECA) data indicate a higher rate of lifetime major depressive disorder among smokers who have tried unsuccessfully to stop smoking compared with never-smokers or smokers who have quit successfully (L. Robbins and J. Helzer, personal communication). However, the second observation that a history of major depressive disorder has a negative influence on the ability to stop smoking is without empirical precedent. Measures of subjects’ postcessation symptoms had been taken in our clonidine trial. We examined these data to determine whether the clinical picture early in the abstinence period could explain the less favorable prognosis for the smoker with a history of depression. We hypothesized that smokers with past depression would experience psychological discomfort during the withdrawal period more severely than would nondepressives; and that such discomfort during acute withdrawal would predict treatment outcome. We were interested both in the effects of an overall symptom measure and in the effects of specific symptoms. This information could be useful in developing specialized interventions for the refractory smoker. METHODS Sample To avoid confounding condition subjects subjects,
effects due to clonidine,
of a double-blind
clonidine
(n = 36) who had completed two dropped
behavioral
treatment
Entry criteria
out before
that subjects
their
smoking
study.
the house in the morning,
Exclusionary
were medical
conditions
drug or alcohol abuse, schizophrenia,
was limited to
38 placebo-assigned
Each
over a 4-week treatment
smokers
to the placebo
Analysis
first week of treatment.)
therapist
be regular
smoke before leaving criteria
who had been randomized
in the present
at least 1 week in the study. (Of the original
completing
from an individual
required
only subjects
trial were included
subject
of 20 or more cigarettes
per day, habitually
and have made at least one previous that might
and current,
increase
received
period. attempt
to quit.
the risk of using clonidine,
current
but not past, major depression.
Data Collection and Measures To measure
a prior history of depression,
and Schizophrenia
(SADS-L),6
trained interviewers. To measure psychological symptoms
experienced
the Lifetime
a semistructured
state early during
during
Version of the Schedule
psychiatric
instrument,
the withdrawal
the first week after a designated
very mild; 2, mild; 3, moderate;
4, severe;
5, extreme)
for Affective Disorders
was administered
period, we obtained
by clinically
subjects’
reports
of
“quit day.” A six-point scale (0, none; 1,
measured
each of these symptoms:
craving,
anxiety, irritability, restlessness, concentration difficulty, appetite increase, and depressive mood. The first six symptoms correspond with the psychological criteria specified in DSM-III-R to comprise nicotine withdrawal.’ We defined symptom
prevalence
intensity
mean values.
by calculating
subject, i.e., total symptom
as a score of 1 or greater We also calculated
count, and obtained
on a 0 to 5 scale and estimated
the total number
the total symptom
across the measured symptoms. Successful outcome at the end of 4 weeks of treatment
intensity
of symptoms
score by summing
was defined by self-reported
symptom
reported
by a
up ratings
abstinence
from
smoking, verified by serum cotinine concentration of less than 15 ng/mL. Subjects who reported smoking or had cotinine measurements in excess of 15 ng/mL by the end of 4 weeks, and dropouts after week 1, were counted as failures. (As stated earlier, two dropouts before week 1 were not included in this analysis since their week 1 data were not available). T tests and chi-square
analyses
were performed
to test the study hypotheses.
352
COVEY, GLASSMAN,
AN0 STETNER
RESULTS
Subjects’ mean age was 34 years (SD = 8.2). They were largely female (69%) and never married (58%). The majority held or were training for professional or managerial occupations (67%); and nearly all had attended college or graduate school (92%). A prior history of major depressive disorder was observed in 56% of the present sample of placebo-assigned subjects. (This proportion is not appreciably different from the figure of 61% previously reported for the overall study sample.) The group’s mean tobacco consumption at baseline was 30 (SD = 10) cigarettes per day. At the end of the 4-week behavioral treatment period, 10 subjects (28%) had quit smoking entirely, while 26 (72%) had not. By the end of week 1, both groups of eventual treatment successes and failures had made substantial reductions in smoking intake. Successes were smoking an average of 2.5 cigarettes per day (SD = 6.2), a reduction of 91% from their baseline smoking level. Eventual treatment failures, on the other hand, were smoking an average of 5.5 cigarettes daily (SD = 5.5), a reduction of 81% from baseline. A comparison of subjects by history of depression on the prevalence of total and individual symptoms during the week following quit day is shown in Table 1. Depressive mood was reported more frequently by past depressives. They also reported a higher symptom count than did nondepressives. Past depressives and their counterparts did not differ in the prevalence of other symptoms. On symptom intensity, smokers with depression history rated depressive mood and concentration difficulty significantly higher than did smokers without past depression. The former also scored higher on the total symptom intensity measure (Table 2). We tested the effect on treatment outcome of our postcessation symptom measures. The week 1 symptom variables that distinguished smokers with past depression from smokers without such a history, i.e., depressive mood, concentration difficulty, total symptom count, and total symptom intensity (Tables 1 and 2), were rated at higher levels by treatment failures (Table 3). Of the other symptoms measured, only craving, which was not related to depression history, showed a significant effect on treatment outcome.
Table 1. Symptom
Prevalence
by History of Depression Historv of Deoression
Present % Individual symptoms Craving Irritability Anxiety Restlessness Appetite increase Difficulty concentrating Depressive mood Symptom count (mean, SD) +x*(Yates) = 5.233, tt = 2.27, P < .03.
P = .02.
100 95 90 85 75 65 75 5.85
Absent
(n) 120) (19) (18) (17) (15) (13) (15) (1.3)
% 100 81 75 81 75 38 31 4.81
(n) (16) (13) (12) (13) (12) (6) (5)* 11.51t
DEPRESSION AND SMOKING
CESSATION
Table 2. Symptom
353
Intensity
by History of Depression
Historv of Deoression Present
Individual symptoms Craving Irritability Anxiety Restlessness Appetite increase Difficulty concentrating Depressive mood Total symptom intensity
Absent
Mean
(SD)
Mean
(SD)
3.40 2.56 2.60 2.40 2.60 1.85 1.85 17.25
(1.1) (1.3) (1.5) (1.4) (1.8) (1.6) (1.4) (7.3)
2.81 2.00 1.75 1.88 2.56 0.81 0.56 12.38
(1.0)
(1.3)
(1.2) (1.3) (1.8) (1.4) (0.9) (5.7)
t 1.63 1.27 1.85 1.14 0.06 2.06t 3.09’ 2.19t
lP< .Ol. tP < .05.
DISCUSSION
Our study sample included a large proportion (56%) of smokers with past major depression. Although this observation corresponds with ECA data showing a higher rate of major depression in smokers who have attempted but failed in cessation attempts compared with nonsmokers or successful quitters, the unusually higher figure we observed may signal that our sample is a highly selected one in terms of psychiatric morbidity. Moreover, their demographic composition, indicating a predominantly middie to upper social class group, and the preponderance of never-married smokers, points to other selection factors. Thus, the generalizability of our findings regarding the effect of postcessation symptoms on outcome to other samples of addicted smokers is open to question. However, our findings may be pertinent for smokers with a past history of depression. Our data showed that this group of smokers experiences more severe symptoms, particularly depressive mood and concentration difficulty, when withdrawing from nicotine than the group without a depression history. Furthermore, these Table 3. Total and Individual Symptom Scores at Week 1 After Quit Day by Treatment Outcome Treatment Outcome Success
Individual symptoms Craving Irritability Anxiety Restlessness Appetite increase Difficulty concentrating Depressive mood Total symptom intensity Total symptom count +P < .Ol.
tP i
.05.
Failure
Mean
(SD)
Mean
(SD)
2.30 2.00 1.60 1.80 3.00 .40 .40 11.50 4.60
(1.1) (1.3) (1.4) (1.1) (1.3) (1.01 (0.4) (5.4) (1.2)
3.46 2.42 2.46 2.31 2.42 1.77 1.61 16.46 5.69
(1.0) 11.3) 11.4) (1.5) (1.9) (1.6) (1.6) (7.1) (1.4)
t 3.191
.87 1.68 .99 .87 2.51t 2.53t 1.99t 2.14t
COVEY, GLASSMAN,
354
AND STETNER
specific symptoms and general psychological discomfort during the abstinent state were associated with a negative treatment outcome. Perhaps, for smokers with past depression, interventions targeted at preventing dysphoric symptoms during withdrawal will increase their chances for successful smoking cessation. The absence of baseline values did not enable us to determine whether the higher level of distress observed immediately upon withdrawal in past depressives represented a change from baseline levels, or merely reflected precessation levels. Thus, it remains to be determined in future work whether the clinical picture we obtained reflects a greater vulnerability to severe nicotine withdrawal on the part of past depressives or a condition of chronic psychological distress. The specific manner in which interventions aimed at preventing depression in nicotine withdrawal should be designed would be guided by such information. As the hazards of cigarette smoking become more widely recognized and the ranks of former smokers continue to grow, the remaining core of current smokers will increasingly include those who are most severely addicted-the heaviest smokers and those least able to stop. The psychiatric profile of this refractory group needs to be defined in epidemiologic studies using representative community samples. Unlike the exsmokers of earlier years, most of whom managed to quit smoking on their own, this group may need specially tailored therapies to break their addiction. The efficacy of symptom-specific interventions should be explored. REFERENCES 1. USDHHS: Reducing the Health Consequences of Smoking. 25 Years of Progress. A Report of the Surgeon General, 1989. Executive Summary. Rockville, MD, Public Health Service, Centers for Disease Control, Office on Smoking and Health 2. USDEW: The Health Consequences of Smoking, Cardiovascular Disease, A Report of the Surgeon General, 1983. Rockville, MD, Public Health Service Publication No. 84-50204 3. Glassman AH, Stetner F, Walsh BT, et al: Heavy smokers, smoking cessation, and clonidine: results of a double-blind, randomized trial. JAMA 259:2863-2866, 1988 4. Hughes JR, Hatsukami DK, Mitchell JE, et al: Prevalence of smoking among psychiatric outpatients. Am J Psychiatry 143:993-997, 1986 5. Kandel DB, Davies M: Adult sequelae of adolescent depressive symptoms. Arch Gen Psychiatry 43~255262, 1986 6. Endicott J, Spitzer RL: A diagnostic interview: The Schedule for Affective Disorders and Schizophrenia. Arch Gen Psychiatry 35:887-844, 1978 7. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3) Revised. Washington, DC, APA, 1987
