Smoking in schizophrenic patients: A critique of the self-medication hypothesis

Abstract

A common remark among laypeople, and notably also among mental health workers, is that individuals with mental illnesses use drugs as self-medication to allay clinical symptoms and the side effects of drug treatments. Roots of the self-medication concept in psychiatry date back at least to the 1980s. Observations that rates of smokers in schizophrenic patients are multiple times the rates for regular smoking in the general population, as well as those with other disorders, proved particularly tempting for a self-medication explanation. Additional evidence came from experiments with animal models exposed to nicotine and the identification of neurobiological mechanisms suggesting self-medication with smoking is a plausible idea. More recently, results from studies comparing smoking and non-smoking schizophrenic patients have led to the questioning of the self-medication hypothesis. Closer examination of the literature points to the possibility that smoking is less beneficial on schizophrenic symptomology than generally assumed while clearly increasing the risk of cancer and other smoking-related diseases responsible for early mortality. It is a good time to examine the evidence for the self-medication concept as it relates to smoking. Our approach is to focus on data addressing direct or implied predictions of the hypothesis in schizophrenic smokers.

Effects of Smoking Status on Remission and Metabolic and Cognitive Outcomes in Schizophrenia Patients Treated with Clozapine

“…Smoking schizophrenia patients might be at risk of an earlier onset of treatment-resistance and thus, are likely to receive clozapine at an earlier time point. In general, several theories that were developed from the clinical observation of increased smoking rates among people with schizophrenia, e. g., compensatory strategy to ameliorate cognitive deficits [45], relieve symptoms (self-medication hypothesis), or reduce drug-levels to improve the burden of side-effects but also neurobiological effects of nicotine, must be considered [46]. For example, 1 rodent study showed that the administration of nicotine effectively reversed acute clozapine-induced memory impairments while this effect was not present for antipsychotics with a higher D 2 -blockade (risperidone, haloperidol) [47].…”

Tobacco smoking and schizophrenia: re-examining the evidence

“…The self-medication hypothesis was initially described by Khantzian on the basis of his observation that people with mental illnesses take cocaine, in his opinion, to self-medicate their symptoms (Khantzian 1997). Later, this finding was employed to explain excessive smoking rates among people with mental illnesses (Manzella 2015).…”

Tobacco craving and withdrawal symptoms in psychiatric patients during a motivational enhancement intervention based on a 26-hour smoking abstinence period

“…Although this population accounts for a growing proportion of all smokers 13,16 , barriers prevent optimal interventions 17,18 . The assumption that smoking cessation may be a risk factor for increased psychopathology in psychiatric patients is widespread 19,20 , although most recent studies emphasize the benefits of cessation 21 and the selfmedication hypothesis of smoking is questioned 22 . In our clinical practice, we frequently encounter patients reporting that they are unable to stop smoking because they fear being unable to tolerate craving symptoms, or missing smoking's benefits of anxiety or stress relief.…”