Smoking bans: A threat to mental health

Any psychiatric nurse will tell you that patient cigarette smoking is as much a feature of psychiatric wards as the patients are themselves. ‘Near impossible to avoid in a place like this,’ a patient of a psychiatric clinic said to me one day. And it wasn’t too long before I saw what they meant.

Upon early morning rising, well before breakfast had been served, the vast majority of patients were in the designated garden area smoking. After meals there they would be again, smoking. Before queuing for medicine, and as soon as the pills had been washed down, a quick cigarette was on nearly everyone’s agenda. In between sessions of group therapy, the clinic halls resembled those of a primary school at bell time. No running allowed, patients almost race walked, the garden their destination. Cigarettes would be pulled from packs before the outside doors were swung open. One step across the threshold and lighters were already lit. First drags had been sucked down before the door had even closed behind.

Soon, if hospital authorities have their way, this scenario will be obsolete across Australia. In an effort to bring inpatient psychiatric facilities in line with all other health care facilities, smoking will no longer be allowed, not anywhere on the premises. Some psychiatric units are already leading the way, having switched their environments to completely smoke free. Designated outdoor smoking areas therefore have now ceased to exist.

All this has to be a good thing right? Patients of psychiatric facilities should surely be just as encouraged to kick cigarettes as any of their general medical facility counterparts. Shouldn’t they?

There are some very significant differences between these two groups of patients that I believe need to be very carefully considered before any attempts to level this smoke-free playing field.

Non-psychiatric, that is general patients, may simply step outside the bounds of the hospital and indulge in a cigarette. They are free to exercise their legal right to smoke without any breach of the hospital’s smoke-free policy. Not so for the psychiatric inpatient, often not permitted to leave the confines of the psychiatric ward.

General hospital admissions these days are usually quite short. Psychiatric patients on the other hand may endure stays of weeks or even months. The environment is often kept very low-stimulus. Days can be long, lonely and uneventful. The chance to smoke can be one of the only ways to help while away the hours or to indulge in anything like a normal social activity; getting together to have a casual smoke in the courtyard.

Admission to hospital can be stressful regardless of the reason to be there. But for a patient with mental illness this is likely a time of great distress. Patients may have been taken forcibly, be feeling highly vulnerable and in a state of emotional and psychological crisis. A habit of smoking may initially be one of their only sources of comfort. A sudden and abrupt plunge into smoking withdrawal could only add to a patient’s distress and seems to be neither smart nor compassionate.

And there is another issue that in my mind is capable of trumping all others. It is called Akathisia. Akathisia is unfortunately a rather common, unintended effect of quite a number of psychiatric medications. The symptoms are unbearable agitation that robs sleep and induces an unstoppable need to move about. The sufferer endures an inexplicable and unbearable sense of impending doom, of dread, that’s carried in the pit of their stomach.

Akathisia is so harrowing a patient may see suicide as the only escape. Akathisia is easily reversed; the offending drugs simply need to be withdrawn. However, it can so easily be overlooked being attributed to a patient’s condition, as it shares many symptoms with those of mental illness. There is one other, relatively simple thing that can alleviate some of Akathisia’s torment. That thing is smoking.

In my book Dying for a Cure I discuss my time with postnatal depression. I also give a detailed account of the various treatments I was given, and the terrible reactions I had to some of them. Though I didn’t know it at the time one of those reactions was Akathisia.

I’d developed severe symptoms during my time in psychiatric hospitals and on psychiatric medication. It was only once off medication that I recovered completely. Careful, in depth research would help me learn that most of my symptoms were actually caused by my body’s response to the medications. Some psychiatric medicines lower the brain’s amount of a chemical called dopamine. This is with the aim of controlling erratic behaviour. Lowering dopamine levels can also cause undesirable reactions, Akathisia for one.