Table 1.

Case study of a woman with bipolar disorder who wanted to give up smoking but was concerned about weight gain and relapse to depression

Ms. A was a 63-year old woman, with a diagnosis of bipolar affective disorder. Her current condition was stable. Her medication included a mood stabilizer (sodium valproate), an antidepressant (fluvoxamine), and simvastatin for hypercholesterolemia. Ms. A saw a psychiatrist monthly and a community mental health service case manager fortnightly. She smoked 25 cigarettes a day, and had made three serious quit attempts in 48 years of smoking, the longest-lasting 2 weeks. Relapses to smoking were precipitated by stress and lowered mood. Ms. A had not previously used pharmacotherapy for smoking cessation. Although she was motivated to quit smoking, she was preoccupied with the possibility of gaining weight, and experiencing a relapse to depression. She was overweight and her diet lacked fruit/vegetables. Ms. A was sedentary and wanted to increase her level of physical activity.

Ms. A participated in a multi-component CVD risk reduction intervention over a 38-week period that provided an intensive psychosocial intervention together with combination nicotine replacement therapy (NRT). In session 1, motivational interviewing techniques examined Ms. A's unhealthy behaviors and goals for change were set. The intervention then sequentially targeted smoking (from week 1), physical activity (from week 4), and diet (from week 7). Ms. A made her first quit attempt 2 weeks into treatment. She used one 21 mg nicotine patch daily and tried one 2 mg nicotine lozenge but disliked the taste. Within a week of commencing the 21 mg patches, she began experiencing nightmares and sleep disturbance, and reported feeling mildly depressed, with initial insomnia, amotivation, and anhedonia. Ms. A smoked 1/2–1 cigarette per day for the next 4 weeks. She was encouraged to persist with the lozenges and used up to five per day. She persisted with the patches, and the sleep disturbance and vivid dreams dissipated. After 6 1/2 weeks, Ms. A had ceased smoking. Ms. A resisted working within a cognitive therapeutic framework and the focus was placed on behavioral strategies such as avoiding coffee first thing in the morning, not smoking inside her home, distraction activities (e.g., knitting, crosswords, cards), and using sugar-free mints. Seven weeks into treatment Ms. A reported the depression had worsened and she was increasingly anxious and irritable. She was less reactive, had difficulty concentrating, and was slowed in her speech and movements. She described feelings of worthlessness and hopelessness, but did not express any suicidal ideation. Increased support options were arranged and Ms. A saw her case manager and psychiatrist more frequently during this time. Her valproate levels were checked and found to be sub-therapeutic, and medication adjustments were made. Ms. A remained abstinent from cigarettes during this time, and the moderate depression resolved by week 14. However from weeks 22–34, she experienced mild depression. During week 22 Ms. A had two cigarettes on two separate days. This smoking relapse coincided with a return of the depressive symptoms. She struggled over the next month, smoking one to four cigarettes per day. However, by week 30, she had stopped smoking, and remained abstinent from cigarettes at the final therapy session at week 38.

Following session 1, Ms. A self-initiated some healthy behaviors based on her existing knowledge of healthy eating. After session 1, she started eating breakfast. By week 3, Ms. A was eating two pieces of fruit a day and cooking a main meal for dinner. She struggled to maintain these positive changes to her diet between weeks 7–12 when her depressive symptoms were at their most severe. By week 26, Ms. A was again eating fresh fruit/vegetables regularly and having three balanced meals a day. She gained 2.7 kg over the first 15 weeks. One year following commencement of treatment, Ms. A's weight remained constant, and by 18 months she was 1.2 kg lighter than her starting weight.

At the commencement of the program, Ms. A was walking only short distances. From weeks 4–14, she was inactive due to the depression. By week 18, Ms. A commenced a walking program. She started by walking 20 min a day four times a week, and increased this to 40 min a day six times a week by the end of the intervention.