Peter Roy-Byrne, MD reviewing Anthenelli RM et al. Ann Intern Med 2013 Sep 16.
Compared with placebo, varenicline doubles quit rates in smokers with treated depression, without exacerbation of depressive symptoms or suicidality.
Depression is associated with elevated rates of smoking, new nicotine dependence, and relapse after smoking cessation. Varenicline has produced greater quit rates than bupropion in some studies of nondepressed smokers, but reports of greater depression and suicidal ideation with this medication have limited its use with depressed patients. In a 12-month, randomized, controlled, manufacturer-funded study, researchers examined the efficacy and safety of 12 weeks of varenicline (0.5–1.0 mg twice daily) and placebo in 525 smokers with recent unipolar depression. Mean depression scores were low, but some patients remained symptomatic; overall, more than 70% of participants were receiving antidepressants.
The rate of smoking cessation was double with varenicline than with placebo (3 months, 36% vs. 16%; 6 months, 25% vs. 12%; 12 months, 20% vs. 10%). Depression and anxiety scores gradually improved over time, with no difference between varenicline and placebo. Rates of suicidal ideation and across the spectrum of adverse events were similar in the two groups.
This study shows that varenicline is safe and effective for smokers with stably treated depression who are interested in quitting. Depressed patients have particular difficulty with withdrawal effects, often prompting a return to smoking. For these patients, therefore, as the authors note, the ability of varenicline to block nicotine’s rewarding effects even as it acts as a partial agonist may be particularly helpful, although it remains unclear whether varenicline’s previously observed superiority over some other treatments extends to this population. Still, its tolerability, safety, and efficacy suggest its viability as a treatment option.