A report released by an expert panel convened by the National Institute of Mental Health indicates that myriad biological, psychological, and social factors play a role in the high smoking rates among people with psychiatric disorders.

Analysis of data from the National Comorbidity Study (NCS), a nationally representative survey of psychiatric disorders in the United States, indicated that 41% of people with psychiatric disorders smoke, nearly twice the rate (22.5%) seen in the general population. Their life expectancy is reduced by 20 years.

Additionally, although people with psychiatric disorders make up 26.2% of the U. S. population, they consume 44.3 percent of all cigarettes smoked, and this high smoking rate is partly to blame for increased rates of physical illness and mortality amongst the mentally ill.

Despite these high smoking rates and their obvious health hazards, studies of psychiatric patient care showed that fewer than 25% of outpatients received smoking cessation counseling, and only 1% of inpatients were assessed for smoking; no treatment plans for these patients addressed tobacco use.

The report says that reasons for these low rates of assessment and treatment include the medical communities acceptance of smoking by psychiatric patients as an individual right and as a method of self-medication and symptom relief.

In order to address the disparities and improve psychiatric patient care and prognoses, the panel identified the following areas for continued research:

* Changes in the hypothalamic-pituitary-adrenal (HPA) axis, a system in the body involved in the response to stress, have been reported in post-traumatic stress disorder (PTSD). The HPA axis is also involved in the development of nicotine tolerance. The interplay of the HPA axis with stress and nicotine may help explain the increased smoking in those with PTSD and other anxiety disorders.

* The possibility that the relationship between depression and smoking is bidirectional: depression increases the risk of smoking, and chronic smoking increases a person's susceptibility to depression. The same genes may contribute to both. For example, decreased activity of dopamine -a neurotransmitter that is central to the brain's reward system-is thought to be associated with depression; studies cited by the panel suggest that variants of genes that affect the level of dopamine function can influence the likelihood that someone with depression will smoke.

* As many as 70 to 85 percent of people with schizophrenia use tobacco. According to the panel, psychosocial factors are important in understanding the high rates of smoking people with schizophrenia. Limited education, poverty, unemployment, and peer influence increase smoking risk; the mental health treatment system, in which smoking is not only acceptable but sometimes condoned, is also a contributor.

* Nicotine has effects on some cognitive processes in people with schizophrenia and research has found that variants in the genes for nicotine receptors have been linked to deficits in these processes. The relationships between genes, environment, and smoking in this population are not fully understood.

The panel also identified these issues for future research:

*Improve precision in defining the specific psychiatric disorders of interest in a given study. "Depression," for example, is used in reference to a number of different conditions. Similarly, clearer definitions of smoking behavior and patterns and progression of use are needed.

* Use longitudinal studies toprovide more complete information on the relative risk, incidence, and course of smoking and various mental disorders.

* Explore the causal links between tobacco use and psychiatric disorders, including possible genetic, neurobiological, psychological, or social factors. The extent to which smoking is used as a form of self-regulation needs to be explored.

* Discover how smoking and other health related factors such as stress, obesity, and limited physical activity contribute to the illness and mortality seen in people with mental disorders.

* Assure adequate sample sizes in smoking cessation trials, and greater emphasis on adapting cessation treatment to various psychiatric populations and in different treatment settings; and research on how tobacco control polices affect psychiatric populations.

With these guidelines in place, psychiatric patients may finally see literal parity on the heels of recent insurance parity; and a mental illness diagnosis will not carry with it a 20-year decrease in life expectancy, as is now the case.

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