摘要：Objectives . Using a brief contact control, we tested the efficacy of a staged care intervention to reduce cigarette smoking among psychiatric patients in outpatient treatment for depression. Methods . We conducted a randomized clinical trial that included assessments at baseline and at months 3, 6, 12, and 18. Three hundred twenty-two patients in mental health outpatient treatment who were diagnosed with depression and smoked ≥1 cigarette per day participated. The desire to quit smoking was not a prerequisite for participation. Staged care intervention participants received computerized motivational feedback at baseline and at 3, 6, and 12 months and were offered a 6-session psychological counseling and pharmacological cessation treatment program. Brief contact control participants received a self-help guide and referral list of local smoking-treatment providers. Results . As we hypothesized, abstinence rates among staged care intervention participants exceeded those of brief contact control participants at months 12 and 18. Significant differences favoring staged care intervention also were found in occurrence of a quit attempt and stringency of abstinence goal. Conclusion . The data suggest that individuals in psychiatric treatment for depression can be aided in quitting smoking through use of staged care interventions and that smoking cessation interventions used in the general population can be implemented in psychiatric outpatient settings. The mental health system has been reluctant to identify and treat tobacco dependence despite exhortations to diagnose and treat this often fatal disorder. 1 , 2 This phenomenon can be linked to the belief on the part of mental health professionals that they do not have the skills to provide smoking treatment, the failure to understand that mental health patients can succeed in quitting smoking, reimbursement concerns, and fear of exacerbation of symptoms during nicotine withdrawal. 2 , 3 Also, it is sometimes assumed that individuals with mental illness are too distracted, demoralized, or disorganized to benefit from smoking treatment. One large-scale recent study estimated that 44.3% of the cigarettes smoked in this country are smoked by individuals with a psychiatric disorder, such as substance abuse and dependence, schizophrenia, bipolar disorder, and major depressive disorder (MDD). 4 Depressed smokers may be numerically the largest group of comorbid smokers, because of considerable co-occurrence, as well as the high incidence and prevalence of depression. 5 There are compelling arguments for the provision of smoking treatment in the psychiatric outpatient setting. The first such argument is the high prevalence of cigarette smoking in that setting. 6 , 7 Second, if smoking cessation exacerbates psychiatric disorders, quitting smoking while in treatment would provide a safety net. 3 Third, although mental health providers may view themselves as unable to skillfully provide nicotine-dependence treatment, they already possess the basic tools needed to provide such treatment, including interviewing and behavior change methods and knowledge of psychopharmacology. The Agency for Health Care Policy and Research guidelines 8 and the American Psychiatric Association practice guidelines 9 available at the time this study was initiated (in 1999) suggested that smokers with comorbid mental health conditions should be offered the same smoking cessation treatments that have been identified as effective for smokers in general: skill training, pharmacotherapy, and clinical support. It is important to note that these recommendations are not currently implemented in mental health treatment settings. 1 The clinical trial described in our article tested the efficacy of a staged care intervention that was implemented in the mental health outpatient setting and was designed to change smoking behavior in all smokers, including those unmotivated to quit. The target population of interest was patients in outpatient treatment for depression. The staged care intervention was an appropriate intervention for smokers enrolled in depression treatment, because smoking cessation would not be a primary goal for these individuals. Yet, their presence in the mental health treatment setting provided an opportunity to intervene in their smoking behavior. The staged care intervention operationalized the recommendations of the Agency for Health Care Policy and Research and the American Psychiatric Association practice guidelines. 8 , 9 It integrated a computerized feedback system that was based on the Transtheoretical Model, which provided feedback about smoking with a provision for face-to-face individual psychological counseling and pharmacological treatment at the appropriate stage of readiness. 10 The staged care intervention was compared with an educational materials and referral list control (brief contact control). The control condition was designed to model current practices in mental health clinics, although in practice it probably exceeded those usually provided. We proposed 4 hypotheses: (1) staged care intervention participants will be more likely to be abstinent from cigarettes at months 12 and 18 than participants in the brief contact control group. Observed effect sizes on interventions with smokers who may not be ready to quit smoking have been observed in the literature, 11 , 12 and, in light of these findings we did not expect significant differences in abstinence rates at months 3 and 6. (2) Staged care intervention participants will be more likely to report at least 1 attempt at quitting smoking than brief contact control participants at months 3, 6, 12, and 18. (3) At months 3, 6, 12, and 18, staged care intervention participants will have more stringent smoking abstinence goals than brief contact control participants. (4) Independent of treatment condition, less severe depressive symptoms measured at baseline with the Beck Depression Index (BDI-II) will predict abstinence from cigarettes at months 3, 6, 12, and 18. 13
