Patterns of Change in Depressive Symptoms During Smoking Cessation: Who’s at Risk for Relapse?

Abstract

A disproportionately high percentage of smokers participating in smoking cessation studies are found to have a lifetime history of major depression disorder (MDD). The prevalence of a history of MDD in smokers entering treatment has ranged from 22% to 61% (Ginsberg, Hall, Reus, & Muñoz, 1995; Glassman et al., 1988; Hall, Muñoz, & Reus, 1994; Hall et al., 1996; Kinnunen, Doherty, Militello, & Garvey, 1996). This is considerably higher than the lifetime prevalence of MDD in the general population, which is approximately 17% (Kessler, 1994). Population and community studies have confirmed the importance of a history of MDD in relation to smoking status and nicotine dependence. In a catchment area survey (Glassman et al., 1990), an MDD history was more common in smokers than nonsmokers and was associated with greater frequency of regular smoking. Likewise, in a community survey, lifetime history of MDD was associated with increased smoking prevalence in both men and women (S. Cohen, Schwartz, Bromet, & Parkinson, 1991).

A history of MDD appears to impede efforts at smoking cessation. In treatment studies, Glassman and colleagues found positive MDD history predicted poorer smoking outcome at both 4-weeks (Glassman et al., 1988) and 10-weeks postquit date (Glassman et al., 1993). However, in treatment studies with longer follow-ups, MDD history failed to predict smoking status at 52-weeks postquit date (Ginsberg et al., 1995; Hall et al., 1994). Survey research also indicates a deleterious effect of MDD history on quitting smoking; individuals with a history of MDD are less likely to have quit smoking than individuals without such a history (Glassman et al., 1990).

Why do smokers with a history of MDD have poor outcomes in smoking cessation? One theory suggests that smokers with a history of MDD self-medicate with nicotine and subsequently begin to experience an increase in depressive symptoms when they quit smoking (Hughes, 1988). This increase in depressive symptoms may then undermine their quit attempt because of decreased motivation or decreased self-efficacy. Indeed, smokers with an MDD history are more likely to report elevated depressed mood while quitting than are smokers without an MDD history (Breslau, Kilbey, & Andreski, 1992; Covey, Glassman, & Stetner, 1990; Ginsberg et al., 1995; Hall et al., 1994, 1996), and increases in depressed mood immediately after quitting predict relapse to smoking (Covey et al., 1990; Hall et al., 1996). Finally, Covey, Glassman, and Stetner (1997) found that a greater percentage of smokers with a history of recurrent MDD (30%) experienced a new major depressive episode following quitting as compared with smokers with a single past episode (17%) or no history of MDD (2%).

Given the relationship between depressive symptoms–depressed mood and smoking cessation in smokers with a history of MDD, several attempts have been made to increase smoking cessation success in history positive smokers by adding coping skills for depression–negative mood to standard smoking cessation treatments. Two studies have found significant effects of mood-management skills for smokers with an MDD history when the experimental treatment had greater therapist contact time than the control (Hall et al., 1994, 1998). However, in a study that equated for therapist contact between conditions, no significant differences were found between standard smoking cessation treatment and standard treatment with the addition of a mood-management component (Hall et al., 1996). Also, in each of the Hall et al. studies (Hall et al., 1994, 1996, 1998), mood management did not attenuate postcessation increases in depressive symptoms among smokers with an MDD history.

In a recent study of smokers with a history of MDD, we found that cognitive–behavioral therapy for depression (CBT-D), when incorporated into standard smoking cessation treatment (ST), led to better outcomes for heavier smokers and for smokers with a history of recurrent, but not of single-episode, MDD (Brown et al., 2001). CBT-D did not, however, decrease depressive symptoms prior to or after quitting. Also, contrary to expectations, depressive symptoms in the sample as a whole did not increase significantly following quit date. These findings led us to question how many smokers with an MDD history show a pattern of increasing depressive symptoms during quitting and what other patterns of change in depressive symptoms could be identified within this population. In this article, we use cluster analysis to classify patterns of change in depressive symptoms in smokers with a history of MDD. We then examine the relationship of these patterns of change to treatment outcome and to baseline characteristics.

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