Major depression and dysthymia are common illnesses. Incidence among the general population range from 10–15%, some say even higher. There does appear to be a link between smoking and depression although it isn’t yet well understood. Smokers have more symptoms of depression. Depressed patients are less likely to stop smoking and have a greater dependence on cigarettes.

Smoking cessation does indeed cause increased symptoms of depression. Smokers with current or past depression who have stopped smoking are more likely to relapse than non-depressed individuals.

There are mixed reports on the effects of the use of varenicline on depression in smoking cessation. Some suggest an exacerbation of depression while others have suggested improvement using varenicline vs cessation without pharmacological aides. The biological is presently unknown.

Of course, regardless of whether a patient is going to quit smoking, it’s very important to be screening for depression. Not only is it common but its consequences for morbidity and mortality are significant. That having been said, you might want to modify your strategy a little with smokers. I’d advise screening for depression concurrently and treating it if it’s present. If it isn’t, but there’s a history of depression, you might want to start prophylaxis for depression prior to quitting smoking. You should advise these patients that they might have an increase in depressive symptoms while trying to quit smoking, and strategize with them about coping with this. In addition, you should be prepared for a higher relapse rate and more frequent attempts before success.

Although some of these strategies (e.g. pretreatment with antidepressants) haven’t been studied adequately and therefore there’s no actual evidence for them, they’re neither difficult nor dangerous to implement.

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