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2021 Rygestop Og Psykiatri 2021 Rygestop og psykiatri Betydning af tobaksrygning og rygestop for psykiatriske symptomer og behovet for psykofarmaka Rygestop og psykiatri Side 2/174 Rygestop og psykiatri Betydning af tobaksrygning og rygestop for psykiatriske symptomer og behovet for psykofarmaka © Sundhedsstyrelsen, 2021. Publikationen kan frit refereres med tydelig kildeangivelse. Sundhedsstyrelsen Islands Brygge 67 2300 København S www.sst.dk Elektronisk ISBN: 978-87-7014-356-1 Den trykte versions ISBN: 978-87-7014-356-1 Sprog: Dansk Version: 1 Versionsdato: 14. juni 2021 Format: pdf Rapporten er udarbejdet af Institut for Lægemiddeldesign og Farmakologi ved Københavns Universitet, på vegne af Sundhedsstyrelsen. For Institut for Lægemiddeldesign og Farmakologi, Københavns Universitet: Jesper Tobias Andreasen Udgivet af Sundhedsstyrelsen, Juni 2021 Rygestop og psykiatri Side 3/174 Indholdsfortegnelse Forord ............................................................................................................................... 7 Resume ............................................................................................................................. 8 Summary ........................................................................................................................ 10 1. Hvorfor er rygestop i psykiatrien relevant? ............................................................ 12 2. Introduktion ................................................................................................................ 14 3. Tobaksrøg: indholdsstoffer, effekter og betydningen for psykiatriske symptomer ..................................................................................................................... 15 3.1. Nikotin ............................................................................................................................... 17 3.1.1. Farmakodynamik ....................................................................................................... 17 Nikotin efterligner hjernens signalstof acetylkolin ............................................................... 17 Længerevarende nikotinforbrug opregulerer antallet af receptorer ................................... 18 Effekter af akut og kronisk nikotin ....................................................................................... 19 3.1.2. Farmakokinetik .......................................................................................................... 20 3.2. Andre stoffer i tobaksrøg ............................................................................................... 21 3.3. Tobaksafhængighed og psykisk sygdom .................................................................... 21 3.3.1. Rusmiddelafhængighed og ’dobbelt-diagnoser’ ....................................................... 21 3.3.2. Rusmiddelafhængighed hænger tæt sammen med andre psykiatriske diagnoser ............................................................................................................................. 22 3.3.3. Nikotinafhængighed: dopamin og kontekst er nøglefaktorer ................................... 23 4. Årsagssammenhænge mellem tobaksrygning og psykiske lidelser .................... 24 4.1. Hypoteser om årsagssammenhænge ........................................................................... 24 4.2. Hvordan kan årsagssammenhænge mellem tobaksafhængighed og psykiske lidelser belyses? .................................................................................................... 26 4.2.1. Observationsstudier .................................................................................................. 26 4.2.2. ’Risk ratio’, ’hazard ratio’ or ’odds ratio’ som mål for graden af association mellem eksponering og udfald ............................................................................................ 26 4.2.3. Interventionsstudier på mennesker og dyr ............................................................... 28 4.2.4. Genome-Wide Association Study og Mendelsk randomisering .............................. 28 4.3. Angst og tobaksrygning ................................................................................................. 30 4.3.1. Selvmedicinering ....................................................................................................... 31 4.3.2. Toksicitet af tobak og nikotin ..................................................................................... 32 4.4. Unipolar depression og tobaksrygning ........................................................................ 34 4.4.1. Selvmedicinering ....................................................................................................... 34 4.4.2. Toksicitet af tobak og nikotin ..................................................................................... 35 4.5. Bipolar lidelse og tobaksrygning .................................................................................. 37 4.5.1. Selvmedicinering ....................................................................................................... 38 4.5.2. Toksicitet af tobak og nikotin ..................................................................................... 38 4.6. Skizofreni og tobaksrygning .......................................................................................... 39 4.6.1. Selvmedicinering ....................................................................................................... 40 4.6.2. Toksicitet af tobak og nikotin ..................................................................................... 41 4.7. ADHD og tobaksrygning ................................................................................................. 42 4.7.1. Selvmedicinering ....................................................................................................... 43 4.7.2. Toksicitet af tobak og nikotin ..................................................................................... 44 4.8. Teenagere er en særlig risikogruppe ............................................................................ 44 Rygestop og psykiatri Side 4/174 4.9. Samlet om associationen mellem sindslidelser og tobaksrygning ......................... 46 5. Tobaksrøg: indholdsstoffer og deres betydning for omsætningen og effekten af psykofarmaka.............................................................................................. 51 5.1. Farmakodynamiske interaktioner mellem tobaksrøg og psykofarmaka ................. 51 5.2. Farmakokinetiske interaktioner mellem tobaksrøg og psykofarmaka..................... 52 5.2.1. Opsummering ............................................................................................................ 53 6. Effekt af tobaksrygning eller rygestop på farmakokinetikken af psykofarmaka ................................................................................................................ 53 6.1. Tricykliske antidepressiva (TCA) .................................................................................. 54 6.1.1. Amitriptylin og nortriptylin .......................................................................................... 54 6.1.2. Clomipramin............................................................................................................... 54 6.1.3. Doxepin ...................................................................................................................... 55 6.1.4. Imipramin og desipramin ........................................................................................... 55 6.2. Selektive serotonin-optags-hæmmere (SSRI) ............................................................. 56 6.2.1. Citalopram og escitalopram ...................................................................................... 56 6.2.2. Fluoxetin .................................................................................................................... 56 6.2.3. Fluxoxamin ................................................................................................................ 56 6.2.4. Sertralin ...................................................................................................................... 57 6.3. Dual-uptake-hæmmere (SNRI/DNRI) ............................................................................. 57 6.3.1. Venlafaxin .................................................................................................................. 57 6.3.2. Duloxetin .................................................................................................................... 58 6.3.3. Bupropion .................................................................................................................. 58 6.4. Atypiske antidepressiva ................................................................................................. 58 6.4.1. Agomelatin ................................................................................................................. 58 6.4.2. Trazodon .................................................................................................................... 59 6.4.3. Mianserin ................................................................................................................... 59 6.4.4. Mirtazapine ................................................................................................................ 59 6.5. Monoamin-oxidase-hæmmere ....................................................................................... 59 6.5.1. Moclobemid
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