The above warning is necessary, in part, because the meaning of the word "depression" can vary greatly. Like the vague word "crave" ranging from a barely noticeable urge to full-blown panic, the word depression can range from a short period of normal and expected sadness to full-blown clinical long-term (chronic) depression with suicidal thoughts, planning, or attempts.
I'm not a doctor. I have no medical training. I'm a nicotine cessation educator. While I share basic recovery information, it usually reflects averages from studies. Call and get seen ASAP if you or loved ones are concerned about any symptom. Call 911 immediately if having thoughts of harming yourself. If reluctant do so, at least tell a friend or type "suicide hotline" into any search engine and call now.
That said, let's briefly overview depression generally before focus upon sadness or depression associated with ending nicotine use. First, the good news -- from studies -- for those experiencing pre-cessation depression.
While evidence continues to build that adolescent nicotine use can contribute to causing depression,[1] researchers report no difference in either short-term (less than 3 months) or long-term recovery success rates (greater than 6 months), between smokers with a history of depression and those without.[2]
According to the U.S. National Institute of Mental Health (NIMH), we all occasionally feel sad or blue but normally such feelings pass within a couple of days.
There are many types of depression and no one single cause. It likely results from a combination of factors, including psychological, biochemical, environmental, and genetic.
The NIMH states that symptoms of depression may include persistent sadness, anxiousness or "empty" feelings, feelings of hopelessness and/or pessimism, feelings of guilt, worthlessness and/or helplessness, irritability, restlessness, loss of interest in activities or hobbies once pleasurable including sex, fatigue and decreased energy, difficulty concentrating, remembering details and making decisions, insomnia, early-morning wakefulness, or excessive sleeping, overeating, or appetite loss, thoughts of suicide, suicide attempts, persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment.[3]
The American Psychiatric Association's DSM-IV manual (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) provides standards for diagnosing depression.
What are the symptoms of major clinical depression? Before reviewing them, do NOT use the following list to attempt to self diagnose yourself, as the DSM-IV standards have other depression definitions too, which include many, many qualifiers. It's why we have highly trained mental health professionals such as psychiatrists.
Generally, under DSM-IV standards, a person must exhibit at least 5 of the following 9 symptoms for at least two weeks in order to be diagnosed as having "major depressive disorder" or MDD: (1) feeling sad, blue, tearful; (2) losing interest or pleasure in things we previously enjoyed; (3) appetite much less or greater than usual, accompanied by weight loss or gain; (4) a lot of trouble sleeping or sleeping too much; (5) becoming so agitated, restless or slowed down that others begin noticing; (6) being tired without energy; (7) feeling worthless or excessive guilt about things we did or didn't do; (8) trouble concentrating, thinking clearly or making decisions; (9) feeling we'd be better off dead or having thoughts about killing ourselves.
Even if a person exhibits 5 of the above 9 symptoms, the symptoms cannot indicate a mixed episode, must cause great distress or difficulty in functioning at home, work, or other important areas, and may not be caused by substance use (e.g., alcohol, drugs, medication).
Even if a patient otherwise meets the DSM-IV criteria to be diagnosed with depression, they are excluded and denied the diagnosis if their depression is a normal reaction to the death of a loved one (the "bereavement exclusion") or induced by alcohol or drug use.
So, why exclude drug-induced depression but not depression related to ending drug use? Why is it normal to experience depression related to the loss of a loved one, but not when the loss is associated with ending a long and intense chemical relationship?
Normal Sense of Emotional Loss
Sadness and depression are commonly seen in association with withdrawal from most addictive substances. During nicotine withdrawal, both temporary neuro-chemical de-sensitization and a normal psychological-emotional loss can give rise to sadness and depressive-type symptoms.
Recovery reflects the end of a long and intensely dependent chemical relationship. As the brain restores sensitivities, physiological, psychological, and emotional bonds are broken. Some degree of sense-of-loss sadness is normal and expected.
Should moods fostered by a healing brain or due to normal and expected sadness be classified as clinical depression and mental illness? "Probably not," says a leading U.S. expert.
Dr. Michael First is a physician and psychiatry professor at Columbia University Medical Center and helped write the DSM-IV standards.[4] Dr. First did an interview with National Public Radio in April 2007.
During the interview, he discussed a study he co-authored that sheds light on whether or not the DSM-IV "bereavement exclusion" should extend to "other types of losses," where it is normal to expect temporary depression.
"For some people, a very messy divorce, a loss of a job, suddenly, those can be just as traumatic as the loss of a loved one," said Dr. First. According to Dr. First, to fall under the "bereavement exclusion" for normal, expected and temporary depression, the depression has to "last less than two months and be relatively mild."
"For instance, it would not include symptoms such as suicidal ideation or severe slowing down in the way you talk. So it was a mild version of depression that occurred following a loss such as divorce and other things like that."[5]
Dr. First's 2008 study reviewed a national mental health survey and found that "25% of people who were diagnosed with major depressive disorder in the study looked just like the people who we would consider to have normal grief."[6] "So it really raises questions about whether or not these individuals should be considered normal in the same way someone who has normal grief would be considered normal."
He was asked about treatment of those experiencing normal and expected sadness. "When a clinician makes a decision about whether to use psychotherapy or mediation or some combination, the severity of the symptoms play an important role," he notes.
"And certainly if someone is felt to have a normal reaction to the loss of a loved one or a stressful situation, probably the clinician would err on the side of being less aggressive with respect to treatment." Although normal sadness might benefit from medication, Dr. First reminded listeners that "medications have side effects" and any potential benefits must be weighed against them.
Although recovery may feel like the death of a friend or loved one, in truth it's an end to chemical captivity. While normal to feel a sense of loss, how do we know that what we're feeling is normal sadness and not full-blown major clinical depression?
Self-diagnoses is dangerous. The best advice I can give is that if you think that you are experiencing depression that isn't lifting, or your family is noticing mood changes, get seen and evaluated as soon as possible by your medical provider or at the nearest emergency medical facility.
In regard to depressive type symptoms associated with cold turkey nicotine cessation, it may or may not fall under the "bereavement exclusion," depending on whether symptoms are relatively mild and it doesn't last longer than two months.[7]
The more fundamental question is, "why" is sadness or depression a normal step in the emotional grieving process? What's the purpose of depression?
While the anger phase of emotional recovery is fueled by anxiety (Chapter 10), depression is emotional surrender. It reflects a wide spectrum of varying degrees of hopelessness, where anxieties often subside.
Psychiatrist Paul Keedwell suggests that depression is part of what it means to be human, that it's a defense rather than a defect.
Dr. Keedwell contends that depression forces us to pause and evaluate loss, to change or alter damaging situations or behavior, and that upon reflection and recovery we often experience greater sensitivity, increased productivity, and richer lives.[8]
While successful nicotine dependency recovery demands a degree of reflection, obviously not all depression falls within the "bereavement exclusion," is "relatively minor" in nature, nor improves within 60 days.
In the Ward "abstinence effects" study, 39% of smokers entering the study reported experiencing depression on the day before commencing recovery. By comparison, 19% of never-smokers in the control group were also then experiencing depression.
The percentage experiencing depressive-type symptoms during recovery peaked at 53% on day three and fell to 33% (6 points below the group's 39% starting baseline) by day seven.
Amazingly, only 20% of ex-smokers were reporting depressive-type symptoms by day twenty-eight, just one percentage point above the rate of non-smokers in the control group.[9]
It was once thought that those with depression smoked in order to self-medicate. But as suggested by Ward's finding, researchers are now asking, "Which came first, nicotine addiction or depression?"[10]
We know that if nicotine replenishment is delayed, an escalating sense of depression is felt, which is often accompanied by increasing anxiety and frustration.
We also know that youth who take up smoking report increased levels of anxiety, stress, and depression, and that adults experience "enduring mood improvements" after stopping.[11]
Hopefully, education and self-honesty will aid in more quickly putting any normal sense of loss blues behind you. If depressed while you were using, once through withdrawal, hopefully, your mood will change for the better.
Zyban, Wellbutrin, Chantix and Champix
Keep in mind that the physician's depression treatment resources include not only counseling but scores of non-nicotine and non-addictive medications including Wellbutrin (whose active chemical is bupropion), which is marketed as the stop smoking pill Zyban.
Although long-term results from real-world cessation method surveys indicate that Zyban may be no more effective than attempting recovery without it,[12] it doesn't mean that bupropion does not benefit those experiencing depression.
I also want to briefly mention varenicline which is marketed in the U.S. as Chantix and elsewhere as Champix. Although we had no reported case or medical journal article discussing anyone stopping cold turkey having ever attempted suicide prior to Chantix, on April 1, 2008, the U.S. Food and Drug Administration reported that:
"Chantix has been linked to serious neuropsychiatric problems, including changes in behavior, agitation, depressed mood, suicidal ideation and suicide. The drug may cause an existing psychiatric illness to worsen, or an old psychiatric illness to recur. The symptoms may occur even after the drug is discontinued."[13]
I mention varenicline for two reasons. First, in arguments intended to help salvage varenicline from the FDA recall chopping block, Pfizer (the pharmaceutical company marketing varenicline) has come dangerously close to suggesting that depression in those stopping cold turkey can become so great that they too commit suicide. Nonsense!
Varenicline is what's termed a partial agonist. It stimulates dopamine pathways via the same nicotinic-type acetylcholine receptors that nicotine would have occupied, while at the same time blocking nicotine's ability to occupy the receptor and induce stimulation.[14]
But receptor stimulation by varenicline is significantly less than with nicotine (35 to 60%).[15] This reduced level of stimulation may not be sufficient to prevent some having certain pre-existing underlying disorders (such as depression or other mental health disorders) from experiencing the onset of serious depression and/or behavioral changes.
The problem is that varenicline's elimination half-life is 24 hours.[16] It means that even if the user realizes that the medication is affecting their mood or behavior, that even if they stop taking varenicline immediately, that they'll only reduce its influence by half after a full day without it.
So long as varenicline's stimulation blocking effects remain present, could it be that for some small percentage of users, that the only way they see to bring their suffering to an end is to contemplate ending life itself? It's only a theory. We don't yet know.
The National Institute of Health maintains the www.PubMed.gov website, which indexes and allows searching of the summaries (abstracts) of nearly all medical journal articles and studies.
My June 14, 2012 search of the term "smoking cessation" returned 22,042 papers, while a search of "suicide" identified 56,345. But when the two terms were combined into a single search ("smoking cessation" + suicide) only 61 papers were returned, and nearly all were associated with cessation medications.
I could not locate a single research paper documenting that anyone going cold turkey had ever attempted suicide. Not one.
Those going cold turkey do not use chemicals that prevent their dopamine pathway receptors from being stimulated naturally. Nor is there any chemical preventing their brain from rapidly re-sensitizing receptors and down-regulating receptor counts to levels seen in non-smokers.
As an avenue of last resort, even if they were to begin feeling the effects of untreated major depression, there was no chemical blocking and preventing stimulation.
What we know with certainty is that smokers attempt to stop smoking in order to save and extend their life, not end it.
Seek help immediately if feeling overwhelmed by feelings of depression and sadness. Go to the nearest emergency medical facility if necessary.
Why allow treatable depression to bring you to the brink of relapse? Why allow it to serve as an excuse for continued use when chronic nicotine use likely contributed to causing it?[17] Instead, put a skilled physician on the team.
Given proper treatment, there is absolutely zero evidence to suggest that anyone with a mental health condition - including chronic depression - cannot succeed in gaining freedom from nicotine.
Loneliness or Feeling Cooped Up
Akin to the "sense of loss" felt with depression, loneliness is natural anytime we leave behind a long-term companion, even if a super-toxin. It's time to gift ourselves a new companion, a healing and healthier "us."
Climb from the deep, deep rut we once called home and sample the flavor of nicotine-free life.
Many of us smokers severely limited the activities we were willing to engage in, either because they were too long and interfered with our ability to refuel, or because our body couldn't muster the stamina needed to do them.
Carbon monoxide's four-hour half-life robbed our blood of the ability to deliver enough oxygen so as to allow the moderate to heavy smoker to engage in prolonged periods of vigorous physical activity.
Lonely? Get to know the gradually emerging you. Be brave. Climb from dependency's ditch and head in directions once avoided. If able, sample the healing within by pushing your body a bit harder than normal.
One of the most satisfying aspects of recovery can be exploring life as an ex-user. Climb out, look around, inhale deeply, bask, savor and enjoy.
References:
2. Hitsman B, et al, History of depression and smoking cessation outcome: a meta-analysis, Journal of Consulting and Clinical Psychology, August 2003, Volume 71(4), Pages 657-663.
3. U.S. National Institute of Mental Health, Depression, Internet article last reviewed April 3, 2008, accessed July 19, 2008.
4. Columbia University Medical Center, Department of Psychiatry, Michael First MD, Faculty Profile, updated 2005, viewed July 24, 2008.
5. National Public Radio, All Things Considered, The Clinical Definition of Depression May Change, April 3, 2007 www.npr.org; also see Wakefield JC, et al, Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey, Archives of General Psychiatry, April 2007, Volume 64(4), Pages 433-440.
6. Wakefield JC, et al, Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey, Archives of General Psychiatry, April 2007, Volume 64(4), Pages 433-440.
7. National Public Radio, All Things Considered, The Clinical Definition of Depression May Change, April 3, 2007 www.npr.org; also see Wakefield JC, et al, Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey, Archives of General Psychiatry, April 2007, Volume 64(4), Pages 433-440.
8. Keedwell, Paul, How Sadness Survived, the evolutionary basis of depression, 2008, Radcliffe Publishing, ISBN-10 1 84619 013 4
9. Ward, MM et al, Self-reported abstinence effects in the first month after smoking cessation, Addictive Behaviors, May-June 2001, Volume 26(3), Pages 311-327.
10. Xu Z, et al, Adolescent nicotine administration alters serotonin receptors and cell signaling mediated through adenylyl cyclase, Brain Research, October 4, 2002, Volume 951(2), Pages 280-292; also Boden JM, et al, Cigarette smoking and depression: tests of causal n322ages using a longitudinal birth cohort, British Journal of Psychiatry, June 2010, Volume 196(6), Pages 440-446.
11. Parrott AC, Cigarette-derived nicotine is not a medicine, The World Journal of Biological Psychiatry, April 2003, Volume 4(2), Pages 49-55.
12. Doran CM, et al, Smoking status of Australian general practice patients and their attempts to quit, Addictive Behavior, May 2006, Volume 31(5), Pages 758-766, also see Ferguson J, et al, The English smoking treatment services: one-year outcomes, Addiction, April 2005, Volume 100 Suppl 2, Pages 59-69 [see Table 6]; also Unpublished 2006 U.S. National Cancer Institute Survey of 8,200 quitters, as reported in the Wall Street Journal, Page A1, February 8, 2007.
13. U.S. Food and Drug Administration, FDA Patient Safety News, New Safety Warnings About Chantix, Show #74, April 2008 .
14. Pfizer, Chantix Full Prescribing Information, May 2008, www.Chantix.com
15. Coe JW, et al, Varenicline: an alpha4beta2 nicotinic receptor partial agonist for smoking cessation, Journal of Medicinal Chemistry, May 2005, Volume 48(10), Pages 3474-3477.
16. Pfizer, Chantix Full Prescribing Information, May 2008, www.Chantix.com
17. Sobrian SK, et al, Prenatal cocaine and/or nicotine exposure produces depression and anxiety in aging rats, Progress in Neuropsychopharmacology & Biological Psychiatry, May 2003, Volume 27(3), Pages 501-518.
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