Does smoking reduce akathisia? Testing a narrow version of the self-medication hypothesis

Jose de Leon, Francisco J. Diaz, M. Carmen Aguilar, Dolores Jurado, Manuel Gurpegui

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38 Scopus citations


Background: The self-medication hypothesis proposes that schizophrenia patients smoke to decrease their schizophrenia symptoms or antipsychotic side effects, but they usually start smoking before their illness and heavy smoking is not consistently associated with fewer symptoms or side effects. A narrow version of the self-medication hypothesis, heavy smoking reduces akathisia, is explored. Method: The sample included 250 outpatients with DSM-IV schizophrenia assessed with the Positive and Negative Syndrome Scale (PANSS) and the Barnes Akathisia Scale. Prevalences were 69% (173/250) for smoking, 39% (98/250) for heavy smoking (≥ 30 cigarettes/day), 7% (17/250) for akathisia (Barnes Global score > 1), 14% (35/250) for a broader akathisia definition (Barnes Global score > 0) and 20% for excited symptoms (> 1 on the PANSS factor score). Results: Heavy smoking was not associated with akathisia (41% of patients with akathisia were heavy smokers versus 39% of patients without akathisia; χ2 = 0.3, df = 1, p = 0.86), even after correcting for confounding factors and/or using a broader akathisia definition. Heavy smoking was associated with excited schizophrenia symptoms (possibly reflecting agitation). Particularly in patients taking lower doses of typical antipsychotics, excited symptoms, with or without akathisia, were strongly associated with heavy smoking and appear to interact with patients' reports of smoking's calming effect as the main reason for smoking. Conclusion: The self-medication hypothesis does not explain increased smoking and heavy smoking in schizophrenia. Moreover, heavy smoking may be associated with more disturbed brain homeostatic mechanisms. Prospective studies need to explore whether temporary increases in cigarette smoking may be associated with periods of higher agitation, with or without akathisia.

Original languageEnglish
Pages (from-to)256-268
Number of pages13
JournalSchizophrenia Research
Issue number1-3
StatePublished - Sep 2006

Bibliographical note

Funding Information:
In the past two years, Dr. de Leon has been on the advisory board of Bristol-Myers Squibb; he received investigator-initiated grants from Roche Molecular Systems, Inc, and Eli Lilly Research Foundation; he has lectured once supported by Eli Lilly, once supported by Bristol-Myers Squibb and four times by Roche Molecular Systems, Inc. In the past two years, Dr. Gurpegui has had a research contract with Eli Lilly Research Foundation; he has received honoraria for both lecturing and data collecting from Bristol-Myers Squibb; and he has received travel educational grants from GlaxoSmithKline, Janssen-Cilag, and Lilly. M. Carmen Aguilar's work in this study was supported by a grant from the Spanish Agency for International Cooperation (A.E.C.I.). The authors are grateful to the patients and staff of the Granada-South and Granada-North community mental health centers and their out-patient rehabilitation unit for their collaboration and to the Institutional Review Boards of the ‘San Cecilio’ and ‘Virgen de las Nieves’ University Hospitals who approved the protocol. Juan Rivero, R.N., helped with data collection. Tony Gorge, M.D., suggested the idea that smoking cessation trials are not associated with relevant changes in schizophrenia symptoms. George M. Simpson., M.D., while mentoring the psychopharmacological fellowship training of the first author, described how akathisia and heavy smoking may be associated in some patients.


  • Agitation
  • Akathisia
  • Allostasis
  • Antipsychotics
  • Heavy smoking
  • Schizophrenia
  • Smoking

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Biological Psychiatry


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