People with mental health and addictive (MHA) disorders smoke at high rates and require tobacco treatment as a part of their comprehensive psychiatric care. Psychiatric care providers often do not address tobacco use among people with mental illness, possibly owing to the belief that their patients will not be able to quit successfully or that even short-term abstinence will adversely influence psychiatric status. Progress in the development of treatments has been slow in part because smokers with current MHA disorders have been excluded from most smoking cessation trials. There are several smoking cessation treatment options, including psychological and pharmacological interventions, that should be offered to people with an MHA disorder who smoke. Building motivation and readiness to quit smoking is a major challenge, and therefore motivational interventions are essential. We review the treatment options for people with tobacco dependence and MHA disorders, offer recommendations on tobacco assessment and tailored treatment strategies, and provide suggestions for future research. Treatment efficacy could be enhanced through promoting smoking reduction as an initial treatment goal, extending duration of treatment, and delivering it within an integrated care model that also aims to reduce the availability of tobacco in MHA treatment settings and in the community.

Research has found that repetitive thought processes, such as worry and rumination, play an important role in several disorders; however, these cognitive processes have not yet been examined in insomnia. This study explores rumination and worry in insomnia by examining: 1) whether those high and low on rumination and worry differ on subjective sleep measures, and 2) whether rumination and worry are distinct processes in insomnia. Participants (N = 242) were diagnosed with an insomnia disorder by sleep experts. Participants completed measures of worry and rumination and maintained a 2-week daily sleep log. Results of a multivariate analysis of variance found no main effect of worry; although high and low ruminators differed on several sleep log indices, including sleep efficiency, wakefulness after sleep onset and sleep quality. Factor analysis supported the idea that rumination and worry are separate constructs. Whereas previous research has focused on worry in insomnia, these findings suggest that rumination is important for understanding sleep disturbance. Further, although rumination and worry are both repetitive thought processes, these results indicate that they are distinct processes within insomnia and should be treated as such. The results are discussed with respect to treatment implications for Cognitive Behavioural Therapy for Insomnia.

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Tobacco dependence is the leading cause of death in persons with psychiatric and substance use disorders. This has lead to interest in the development of pharmacological and behavioral treatments for tobacco dependence in this subset of smokers. However, there has been little attention paid to the development of tobacco-free environments in psychiatric institutions despite the creation of smoke-free psychiatric hospitals mandated by the Joint Commission for Accreditation of Health Organizations (JCAHO) in 1992. This review article addresses the reasons why tobacco should be excluded from psychiatric and addictions treatment settings, and strategies that can be employed to initiate and maintain tobacco-free psychiatric settings. Finally, questions for further research in this field are delineated. This Tobacco Reconceptualization in Psychiatry (TRIP) is long overdue, given the clear and compelling benefits of tobacco-free environments in psychiatric institutions.

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Background Patients with schizophrenia have higher rates of smoking (58–88%) than in the general population (~22%), and are more refractory to smoking cessation. These patients also exhibit numerous neurocognitive deficits, some of which may be ameliorated by cigarette smoking. The neurocognitive benefits derived from nicotine may, in turn, contribute to elevated rates of smoking and smoking persistence in schizophrenia. The present study examined the relationship between neurocognitive function and smoking cessation in schizophrenia. Methods Treatment-seeking smokers with schizophrenia (N =58) participated in a 10-week placebo-controlled trial of sustained-release (SR) bupropion plus transdermal nicotine patch. Neuropsychological performance was evaluated in a subset of patients (n=31), prior to pharmacological treatment, using a neurocognitive battery. Results Subjects were compared as a function of endpoint smoking status (Quit versus Not Quit, assessed by end of trial 7-day point prevalence abstinence, confirmed by CO level (<10 ppm) on demographic traits, smoking, and clinical outcomes. While there were no significant baseline differences between quitters and non-quitters, non-quitters exhibited significantly greater deficits in performance on TMT-B (p=0.01) and on Digit Span backwards (p=0.04) compared to quitters. No associations were found between quit status and performance on other neuropsychological measures. Conclusions Our findings extend results of previous studies which suggest deficits in frontal executive function are associated with smoking cessation failure in schizophrenia. This may have implications for the development of tailored smoking cessation treatments in this population.

Assessing for clinical levels of anxiety is crucial, as comorbid insomnias far outnumber primary insomnias (PI). Such assessment is complex since those with Anxiety Disorders (AD) and those with PI have overlapping symptoms. Because of this overlap, we need studies that examine the assessment of anxiety in clinical insomnia groups. Participants (N = 207) were classified as having insomnia: 1) without an anxiety disorder (I-ND), or 2) with an anxiety disorder (I-AD). Mean Beck Anxiety Inventory (BAI) item responses were compared using multivariate analysis of variance (MANOVA) and follow-up ANOVAs. As a validity check, a receiver operating characteristic (ROC) curve analysis was conducted to determine if the BAI suggested clinical cutoff was valid for identifying clinical levels of anxiety in this comorbid patient group. The I-ND had lower mean BAI scores than I-AD. There were significant group differences on 12 BAI items. The ROC curve analysis revealed the suggested BAI cutoff (≥16) had 55% sensitivity and 78% specificity. Although anxiety scores were highest in those with insomnia and an anxiety disorder, those with insomnia only had scores in the mild range for anxiety. Nine items did not distinguish between those insomnia sufferers with and without an anxiety disorder. Additionally, published cutoffs for the BAI were not optimal for identifying anxiety disorders in those with insomnia. Such limitations must be considered before using this measure in insomnia patient groups. In addition, the poor specificity and high number of overlapping symptoms between insomnia and anxiety highlight the diagnostic challenges facing clinicians.

No studies have investigated whether those with poor sleep are aware of being uncomfortable in the dark via subjective inquiry, and no study has evaluated whether poor sleepers have increased fear in the dark using objective indices (e.g., a validated startle paradigm). Good and poor sleepers (N = 108) completed questionnaires about their level of discomfort with the dark and were evaluated for an increased startle reflex by measuring eyeblink latency via electrooculogram in response to unexpected noise in the dark and the light. Participants listened to bursts of unexpected white noise, while in counterbalanced light/dark conditions. Relative to good sleepers, more poor sleepers reported increased discomfort in the dark. There was a significant lighting × time × sleeper status interaction for eyeblink latency. Relative to the first trial in the dark, eyeblink latency in good sleepers increased in the second dark exposure; suggesting habituation in the dark. Eyeblink latency in poor sleepers did not decrease. Thus, poor sleepers reported being uncomfortable in the dark and they remained more easily startled in the dark over the course of the study. It is unclear if the dark may predispose people to sleep problems, or if sleep problems sensitize poor sleepers to fear darkness.