www.forensicnetwork.scot.nh s.uk SoFMH School of Forensic Mental Health An evaluation of the impact of total smoking cessation in a high secure forensic unit in Scotland Dr Briju Prasad Specialty Doctor - Forensic Psychiatry UK National Smoking Cessation Conference Victoria Park Plaza Hotel, London 28 th June 2013
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www.forensicnetwork.scot.nhs.uk
SoFMHSchool of Forensic Mental Health
An evaluation of the impact of total smoking cessation in a high secure forensic unit in Scotland
Dr Briju PrasadSpecialty Doctor - Forensic Psychiatry
UK National Smoking Cessation ConferenceVictoria Park Plaza Hotel, London
28th June 2013
www.forensicnetwork.scot.nhs.uk
SoFMHSchool of Forensic Mental Health
Content of this presentation
• Introduction• Background to smoking and mental health• Aims of this study• Methodology• Results• Limitations and conclusions• Discussion
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SoFMHSchool of Forensic Mental Health
Introduction
• Smoking banned in public places in Scotland since 2006
• Residential mental health units exempt from the ban
• More research in smoking and mental health
• March 2010 Scottish Government guidance –
• Mental health service providers to move towards banning smoking altogether.
• Some mental health units have become smoke free
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SoFMHSchool of Forensic Mental Health
What we know about smokingand mental health…
• Smoking rates - significantly higher
• Highest levels (60-70%) of smoking is among psychiatric inpatients (20-22 % in general population)
• Mental health staff are less positive about smoking cessation in mental health patients
• Life expectancy - 20% less than general population
• Increased rates of cardiac and respiratory diseases (10 times > general population.
• More heavily addicted (>25 cigarettes per day)
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SoFMHSchool of Forensic Mental Health
What we know…
• Increased levels of nicotine dependency
• Quit rates are lower
• Up to 1/3rd of their state benefits is spent on cigarettes
• Strong association between mental illness and smoking• • Smoking does not cause mental illness
• 40-50% of people with depression/ anxiety disorders smoke
• 60-80% of people with Schizophrenia smoke
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SoFMHSchool of Forensic Mental Health
Why do people with mentalhealth issues smoke more?
• Relief of stress
• Self medication
• Increased vulnerability to smoking
• Misleading messages about smoking
• Institutional and cultural factors:– Inpatient psychiatric units– staff/patients beliefs– reward/punish practices.
Deprivation
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SoFMHSchool of Forensic Mental Health
Myths associated withsmoking cessation
“agitated and aggressive”“self harm
more”
“use more medications”
“will not be relaxed”
“psychotic symptoms might get worse”
“irritable and angry”
“mental health will deteriorate”
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SoFMHSchool of Forensic Mental Health
Aims
• To study the beliefs of patients’ and staff before and after smoking cessation
• Compare the effect on weight and physical activity
• Study the change in rates of aggression, psychosis, self harm rates and medications
• Patterns of spending before and after smoking cessation
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SoFMHSchool of Forensic Mental Health
Methodology: Patients’and staff attitudes
• Survey questionnaire had up to 30 questions - 90% patients (n=122) and 61% (n=236) staff
• Respondents:– All patients– Staff (Nursing, Psychology, Pharmacy, Social Work,
Occupational Therapies, activity staff, Dietetics and Medical)
• Five months before and five months after smoking cessation
• Questions
• Anonymous
• Data compared between patients and staff, smokers and non-smokers and pre and post smoking cessation.
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SoFMHSchool of Forensic Mental Health
Methodology : Weight
• Weight: Naturalistic data of body weight (in kg) was retrospectively collated from dietetic hospital records
• Pre smoking cessation: December 2010, June 2011 and December 2011(baseline)
• Post smoking cessation: March, June and December 2012
• Comparisons between smokers and non-smokers, pre and post smoking cessation were analysed
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SoFMHSchool of Forensic Mental Health
Methodology : Behaviouralpatterns
• Assault, aggression and self-harm rates
• Data recorded from hospital Datix security system
• Time scales: One year before and one year after total smoking cessation
• Patterns compared between smokers and non-smokers
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SoFMHSchool of Forensic Mental Health
Methodology : Physicalactivity and spending
• Gym sessions and access to grounds - studied for 12 months before and 12 months after smoking cessation
• Data collected retrospectively from hospital recording systems
• Spending on confectionery and soft drinks patterns were studies 12 months before and 12 months after smoking cessation
• Data collected retrospectively from Hospital shop.
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SoFMHSchool of Forensic Mental Health
Methodology : Medication
• Clozapine – Antipsychotic medication• Plasma levels• Adverse effects – seizures• Dosage• Effect on mental state• Naturalistic data recorded retrospectively a year
before and a year after smoking cessation• Data analysed using SPSS statistical software
• Psychotic symptoms, ‘as required medication’ usage and aggressive incidents did not rise, dispelling myths that restricting smoking would destabilise mental state
• The study revealed patient and staff beliefs about smoking and smoke restriction
• It also highlighted practical considerations relating to patient and staff anxieties about facing smoking restrictions.
• The positive results achieved relating to patients’ mental and physical health, should provide encouragement to other psychiatric units considering smoking restrictions
• Enforcing total smoking cessation in open psychiatric inpatient wards will be more challenging