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When Smoking Is Okay

Not every smoker should quit: When smoking
helps depression.

Here's a message you probably won't see on a cigarette-pack label any time soon: Smokers who suffer from major depression should think twice before trying to give up cigarettes.

Smoking cessation is not only more difficult for those with a history of depression, but also more likely to exacerbate the disorder, according to a Columbia University psychiatrist.

Moreover, nicotine may act as an antidepressant in some people, alleviating fatigue, insomnia, indecisiveness, and suicidal ideation. This may explain why so many people with depression smoke like chimneys, observes Alexander H. Glassman, M.D., in the American Journal of Psychiatry (Vol. 150, No. 4). He urges psychiatrists to be careful when advising depression-prone smokers who wish to say goodbye to the Marlboro Man.

"In an era in which a 'smoke-free' environment is considered desirable, one must wonder if the societal pressure to stop smoking may not, for certain psychiatric patients, have unique risks," Glassman says.

His own research and others' reveals that 75 percent of smokers with a history of major depressive disorder develop depressed mood during the first week of withdrawal, compared to only 30 percent of smokers without such a history. Even worse, their withdrawal period is much more severe, encouraging even the most resolved quitters to resume their smoking habit.

No one knows exactly why. Researchers think that nicotine may increase release of the neurotransmitter dopamine in the nucleus accumbens-an area of the brain responsible for "reward" feelings during eating and sex. People with symptoms of major depression may have a "sluggishly responsive" reward system and may be drawn to nicotine because it perks up this region.

But aren't the health risks of smoking more serious than the possible symptoms of depression? "It all depends," says Glassman, who explains that people who are "psychiatric casualties" of smoking cessation could, at the very worst, commit suicide while in the throes of a depressive episode.

Glassman's advice: Smokers with a history of depression who want to give up cigarettes should consider taking an antidepressant to reduce the risk of provoking depression-especially if nicotine patches and psychotherapy fail to work.