APA 2009: Nicotine Patches Reduce Agitation in Smokers With Schizophrenia

Barbara Boughton

May 19, 2009

May 19, 2009 (San Francisco, California) — Nicotine replacement therapy — specifically 21-mg/day transdermal patches — can decrease agitation and aggressive behavior in hospitalized patients with schizophrenia, according to a randomized controlled trial presented here at the American Psychiatric Association (APA) 162nd Annual Meeting.

Investigators found that nicotine patches decreased agitation to levels seen in treatment with parenteral antipsychotics, according to Michael Allen, MD, from University of Colorado–Denver School of Medicine.

"Seventy percent of people with schizophrenia are smokers. And when they go into a hospital, they're forced to quit smoking. As a result, nicotine withdrawal can increase aggressive behavior. Our study shows that nicotine-replacement therapy can make a big difference in decreasing smoking patients' agitation," Dr. Allen said.

In the study, 40 smokers with schizophrenia, age 18 to 65 years, admitted to the psychiatric emergency unit at the Hospital of the University of Geneva, Switzerland, were screened at baseline for agitation with several measures, including the Agitated Behavior Scale (ABS), the Overt Aggression Scale (OAS), the Positive and Negative Syndrome Scale–Excited Component (PANSS-EC), and the Richmond Agitation Sedation Scale (RASS).

Patients received either a 21-mg transdermal nicotine patch or a placebo patch. At baseline, the OAS was significantly higher in the treatment group than the placebo group. There were no significant differences in other patient characteristics between groups.

Twenty-Four–Hour Trial

During the 24-hour trial, patients who were already receiving adequate treatment continued on the same medications, and those who had gone without treatment or had inadequate treatment received 5 or 10 mg of intramuscular olanzapine or 5 mg of intramuscular haloperidol.

After 4 hours of treatment, the PANSS-EC score decreased from 20.45 to 10.3 in the treatment group and from 20.9 to 12.85 in the placebo group (P = .0004). And after 24 hours, the PANSS-EC score fell further, to 8.1 in the treatment group vs 10 in the placebo group (P = .0111).

Patients' ABS score also decreased, from 28.9 to 17 in the treatment group and from 28.95 to 20.2 in the placebo group (p=.0116). When measured after 24 hours, the ABS scored fell further, to 14.9 in the treatment group vs 16.95 in the placebo group (P = .0491).

Treating Aggression is Costly

Previous research indicates that similar decreases in agitation are seen with treatment of parenteral antipsychotics. Dr. Allen noted that many hospitals do not give nicotine-withdrawal therapy to smokers because of the expense, but treating aggressive behavior in these patients is also costly.

"We'd like to see hospitals take a smoking history and if patients are nicotine dependent, put them on a patch," Dr. Allen said. Although it wasn't tested in the study, nicotine gum could probably have a similar effect on agitation in schizophrenia, he added. However, patches may be superior in decreasing agitation, because the surges of nicotine from gum are somewhat unpredictable.

Although nicotine would not be a good choice for patients who are not smokers, since it can cause nausea and has a short half-life, it should be considered as part of treatment for people with schizophrenia in a hospital setting, he said.

He also noted that since it decreases agitation, nicotine patches could provide added benefit to smoking-cessation programs for smokers who also have schizophrenia.

Provocative and Interesting

"This study is provocative and interesting," commented David Baron, MD, from the Temple University School of Medicine, in Philadelphia, Pennsylvania, and a member of the APA scientific program committee. "This provides us with some important information on the influence of nicotine from a behavioral-health perspective."

Dr. Baron added that smoking has a negative impact on mortality and morbidity among psychiatric patients. The study points to the potential benefits of nicotine-replacement therapy in helping patients with schizophrenia face the tough task of quitting a tobacco habit, he added. "Stop-smoking efforts for people with schizophrenia are likely to have the most efficacy when behavioral and pharmacologic interventions are combined," he said.

The study was funded by the National Alliance for Research on Schizophrenia and Depression. Dr. Allen and Dr. Baron disclosed no relevant financial relationships.

American Psychiatric Association 2009 Annual Meeting: Abstract NR1-019. Presented May 18, 2009.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.