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Archive for January, 2016

The media hype about captagon and its side-effects

by Meryem Grabski @MeryemGrabski

imageTowards the end of last year headlines emerged about captagon, a psychoactive drug “used by the ‘Islamic State’ to create brainwashed, psychotic killing machines”, able to “stay awake days at a time“.  The interest in captagon reached a peak when it was suggested that the terrorists responsible for the attacks in Paris last November may have been under the influence of the drug, a claim that has turned out to be most likely untrue. However, it is not surprising that the potential involvement of a drug in the activities of the “Islamic State” (IS) has been the subject of such media interest, ranging from headlines  about “superhuman soldiers” and “jihad junkies”, to suggestions that captagon is one of the main reasons that the war in Syria is still ongoing. In my research, I spend most of my time trying to find methods that might improve treatments for drug dependence, so I had two immediate reactions to these headlines: curiosity about what this substance really was, and irritation at the superficial, irresponsible way the issue was covered. Motivated by this I would like to look at: a) what information on this drug is actually substantiated, and b) how the sensationalist coverage of drugs has serious negative consequences for people suffering from addictions.

DrugOverdoseThe drug the media are calling captagon has been associated with brand named “captagon”: the psychostimulant fenethylline. However, there is probably a substantial difference between the original formulation and the drug traded as captagon in the Middle East today. Fenethylline was developed in the 1960s and mainly used for the treatment of children suffering from attention deficit hyperactivity disorder (ADHD). In 1986 it was listed by the WHO for international scheduling under the Convention of Psychotropic Substances and banned by most countries. Illegal trade of counterfeit captagon rose afterwards in some Eastern European countries and the Middle East, in particular the Gulf States. However, analyses of pills to be sold as captagon that were seized in Saudia Arabia, Jordan and Serbia have indicated that the amount of genuine fenethylline has decreased over the years, with the most recent studies finding no evidence that fenethylline was present at all. The main active ingredients that were found included amphetamine and caffeine.

The source that most recent media articles on captagon have cited is the BBC Arabic documentary “Syria’s war drug”, which includes interviews with users from Lebanon and Kuwait, and alleged former Syrian fighters. It also touches on the captagon manufacturing and trading processes in Lebanon, as well as its potential connection to groups involved in the Syrian conflict. Importantly, the film makes no claims at any point that this drug is directly related to IS, a fact which has either been ignored or misrepresented in much of the subsequent media coverage.

Apart from the fact that the reporting on captagon has been superficial at best, there is also the issue that sensationalist headlines usually obscure the complexity that underlies any drug story. Oversimplification has been identified as a major problem when it comes to disseminating information on drugs to the public. The media plays a key role in shaping public opinion on drugs, which in turn influences public and criminal justice policy. Direct consequences include the increased use of a certain drug due to its omnipresence in the media, as observed during the discussion of the now illegal substance mephedrone, or the misplacement of governmental resources to overcome perceived, yet unconfirmed, drug threats, as was the case when headlines emerged in the USA linking the use of “bath salts” to extreme violence.

a-stack-of-newspapersBut it is the more long-term, indirect consequences of a sensationalist media discourse that are probably the more harmful ones. The reinforcement of the notion that illegal drugs are one of the main causes and perpetuators of crime is one of them. The recent portrayal of captagon too, supports the idea that drugs are mostly consumed by criminals. The focus was not on how increased use of a drug might harm the civil population in Syria. Instead, news stories attempted to link the drug with IS, the most criminal, abhorrent organization involved in the conflict, despite no good evidence for such a connection. Readers are left with simply a vague association between illegal drugs and terrorism. The stigmatization of people addicted to drugs, increased unfounded public fear of drug-related crimes, and less room for discussions on how we can help prevent and cure addiction are just some of the consequences of inadequate media coverage.

Of course, it is not only sensationalist headlines that lead to these unhelpful consequences, and there are many ways of counteracting them. The provision of information, in as unbiased a way as possible, is one of them. This is where science, and scientists, can play an important role. As well as disseminating their research to the scientific community and publishing in scientific journals, scientists should consider it part of their job to inform and discuss their research publicly. Not only does it help to counter unfounded media stories and inform public opinion – the public engagement opportunities I have had during my PhD so far have been fun and inspiring.

Smoking and chronic mental illness: what’s the best way to quit or cut down?

by Meg Fluharty @MegEliz_

This blog originally appeared on the Mental Elf site on 11th December 2015.

Smoking rates in the US and UK are 2-4 times higher in people with mental illnesses compared to those without (Lasser at al., 2000; Lawerence et al., 2009).

What’s more, smokers suffering from mental illness have higher nicotine dependence and lower quit rates (Smith et al.,2014; Weinberger et al., 2012; Cook et al 2014).

About half of deaths in people with chronic mental illness are due to tobacco related conditions (Callaghan et al., 2014; Kelly et al 2011).

A new ‘state of the art’ review in the BMJ by Tidey and Miller (2015) is therefore much needed, focusing as it does on the treatments currently available for smoking and chronic mental illness, such as schizophrenia, unipolar depression, bipolar depression, anxiety disorders and post-traumatic stress disorder (PTSD).

42% of all cigarettes smoked in England are consumed by people with mental health problems.

42% of all cigarettes smoked in England are consumed by people with mental health problems.


Tidey and Miller (2015) identified studies by searching keywords in PubMed and Science Direct, using relevant guidelines, reviews and meta-analyses, and data from the authors’ own files. Two authors reviewed the references and relevant studies were chosen and summarised. Only peer-reviewed articles published in English were reviewed.

It’s important to stress that this was not a systematic review, so the included studies were not graded, but simply summarised with a particular focus on outcomes.

BMJ State of the Art reviews are not systematic reviews, so are susceptible to the same biases as other literature reviews or expert opinion pieces.  

BMJ State of the Art reviews are not systematic reviews, so are susceptible to the same biases as other literature reviews or expert opinion pieces.



Nicotine replacement therapy (NRT) plus psychosocial

Overall, in studies of NRT with psychosocial treatment (such as CBT) 13% of smokers with schizophrenia averaged 6 to 12 month quit rates. Additionally, those continuing to receive NRT had reduced relapse rates.


Studies investigating bupropion in smokers with schizophrenia found initial abstinence, but were followed by high relapse rates with treatment discontinuation, suggesting the need for longer treatment duration. One study found bupropion coupled with NRT and CBT reduced relapse rates. 


Studies investigating varenicline in smokers with schizophrenia achieved abstinence at the end of the trial (compared to placebo), but not at 12-month follow up. One study found varenicline and CBT had higher abstinence rates at 52 weeks (compared to controls). Psychiatric side effects reported did not differ between groups, suggesting varenicline is well tolerated in schizophrenia.


Studies investigating psychosocial treatments in smokers with schizophrenia were varied. Studies implementing CBT displayed high continuous abstinence, and those receiving motivational interviewing were more likely to seek treatment. However, in contingency management trials (receiving monetary reward for abstinence) it appeared individuals might only be staying abstinent long enough for their reward, therefore longer trials are needed.


One (uncontrolled) study provided e-cigarettes for 52 weeks to smokers with schizophrenia, finding half reduced their smoking by 50% and 14% quit. None of the participants were seeking treatment for cessation at the start of the trial, suggesting a need for further RCTs of e-cigarettes in smokers with schizophrenia.

The Mental Elf looks forward to reporting on RCTs of e-cigarettes in smokers with schizophrenia.

The Mental Elf looks forward to reporting on RCTs of e-cigarettes in smokers with schizophrenia.

Unipolar depression

A review of the cessation treatments available to smokers with unipolar depression found little differences in outcomes between individuals with and without depression. However, women with depression were associated with poorer outcomes. Previous studies indicate bupropion, nortriptyline, and NTR with mood management all effective in smokers with depression. Additionally, a long-term study of varenicline displayed continuous abstinence up to 52 weeks without any additional psychiatric side effects.

Bipolar depression

Few studies investigated cessation treatments in smokers with bipolar depression; two small-scale studies of bupropion and varenicline indicated positive results. However a long-term varenicline study found increased abstinence rates at the end of the trial, but not at 6 month follow-up. Some individuals taking varenicline reported suicidal ideation, but this did not differ from the control group.

Anxiety disorders

An analysis investigating both monotherapy and combination psychotherapies found anxiety disorders to predict poor outcomes at follow-up. Despite combination psychotherapy doubling the likelihood of abstinence in non-anxious smokers, neither monotherapy or combination therapy were more effective than placebo in smokers with a lifetime anxiety disorder. However, unipolar and bipolar only touched on pharmaceutical treatments.

PTSD (Post Traumatic Stress Disorder)

Studies investigating cessation in PTSD sufferers found higher abstinence rates in integrative care treatment, in which cessation treatment is integrated into pre-existing mental healthcare where therapeutic relationships and a set schedule already exist. A pilot study investigating integrative care with bupropion found increased abstinence at 6 months. However, a contingency management trial found no differences between controls, although it’s possible this was due to small numbers.

Standard treatments to help people quit smoking are safe and effective for those of us with mental illness.

Standard treatments to help people quit smoking are safe and effective for those of us with mental illness.


Clinical practice should prioritise cessation treatments for individuals suffering mental illnesses, in order to protect against the high rates of tobacco related death and disease in this population.

This review shows that smokers with mental illness are able to make successful quit attempts using standard cessation approaches, with little adverse effects.

Several studies suggested bupropion and varenicline effective in schizophrenia, and varenicline in unipolar and bipolar depression. However, it should be noted, these studies only investigated long-term depression, not situational depression.

Furthermore, all the participants in the studies reviewed were in stable condition, therefore it’s possible outcomes may be different when patients are not as stable. Individuals whom are not stable will have additional psychiatric challenges, may less likely to stick with their treatment regime, and may be more sensitive to relapse.

It should be noted that this was a ‘state of the art’ review, rather than a systematic review or meta-analysis. Therefore- as all literary reviews-it’s subject to bias and limitations, with possible exclusion of evidence, inclusion of unreliable evidence, or not being as comprehensive as if this were a meta analysed. For example, some of the author’s own files are used along side the literary search, but (presumably unpublished) data from other researchers are not sought out or included. Many of the studies included differed in design (some placebo controlled, some compared against a different active treatment ect.) therefore caution should be taken when drawing comparisons across studies.

Additionally, some sections appeared to be much more thorough than others. For example, schizophrenia is covered extensively, including NTR, psychosocial, and pharmaceutical approaches. While all anxiety disorders appeared to be gaped together as one (as opposed to looking at social anxiety, GAD, or panic disorder) and were not explored in detail, drawing little possible treatment conclusions. Finally, this was great literary review, which provided much information, but at times it did feel a bit overwhelming to read and difficult to identify the key information from each sections.

Service users who smoke are being increasingly marginalised, so practical evidence-based information to support quit attempts at the right time is urgently needed.

Service users who smoke are being increasingly marginalised, so practical evidence-based information to support quit attempts at the right time is urgently needed.


Primary paper

Tidey JW and Miller ME. Smoking cessation and reduction in people with chronic mental illness. BMJ 2015;351:h4065

Other references

Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: a population-based prevalence study.JAMA 2000;284:2606-10 [PubMed abstract]

Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health 2009;9:285

Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the US population. Tob Control 2014;23:e147-53.[Abstract]

Weinberger AH, Pilver CE, Desai RA, et al. The relationship of major depressive disorder and gender to changes in smoking for current and former smokers: longitudinal evaluation in the US population. Addiction 2012;107:1847-56. [PubMed abstract]

Cook BL, Wayne GF, Kafali EN, et al. Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation. JAMA 2014;311:172-82 [PubMed abstract]

Callaghan RC, Veldhuizen S, Jeysingh T, et al. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. J Psychiatr Res 2014;48:102-10 [PubMed abstract]

Kelly DL, McMahon RP, Wehring HJ, et al. Cigarette smoking and mortality risk in people with schizophrenia. Schizophr Bull 2011;37:832-8 [Abstract]

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