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14 - References

References

910 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 12 Movement disorders and Parkinson’s disease By increasing dopaminergic neurotransmission, nicotine is thought to provide a protective effect against both drug-­induced EPSEs and idiopathic Parkinson’s disease. Smokers are less likely to suffer from antipsychotic-­induced movement disorders than non-­smokers5 and use anticholinergic drugs less often.6 Parkinson’s disease occurs less frequently in smokers than in non-­smokers and the onset of clinical symptoms is delayed.5,45 This may reflect the inverse association between Parkinson’s disease and sensation-­seeking behavioural traits, rather than a direct effect of nicotine.46 The protective effect may not be related to nicotine at all but rather to other compounds in tobacco smoke.47 Drug interactions Polycyclic hydrocarbons in tobacco smoke are known to stimulate the hepatic microsomal enzyme system, particularly CYP1A2,7 the enzyme responsible for the metabolism of many psychotropic drugs. Smoking can lower the blood levels of some drugs by more than 50%.7 This can both affect efficacy and influence adverse effects and needs to be taken into account when making clinical decisions. The drugs most likely to be affected are clozapine,48 fluphenazine, haloperidol, chlorpromazine, olanzapine, many tricyclic antidepressants, mirtazapine, fluvoxamine and propranolol. Vaping has no effect on hepatic enzyme function. See ‘Smoking and psychotropic drugs’ in Chapter 11. Smoking cessation and withdrawal symptoms Withdrawal symptoms occur within 6–12 hours of stopping smoking and include intense craving, depressed mood, insomnia, anxiety, restlessness, irritability, difficulty in concentrating and increased appetite. Nicotine withdrawal can be misdiagnosed as depression, anxiety, sleep disorders and mania.49 Withdrawal can also exacerbate the symptoms of schizophrenia.6 See also ‘Nicotine and smoking cessation’ in Chapter 4. References

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