Cognitive enhancers and cosmetic psychiatry: are we ready? A case-report

Expansores cognitivos e psiquiatria cosmética: estamos preparados? Relato de caso

CARTA AOS EDITORES

Cognitive enhancers and cosmetic psychiatry: are we ready? A case-report

Expansores cognitivos e psiquiatria cosmética: estamos preparados? Relato de caso

Dear Editor,

Medical and psychiatric practices are shaped by the social and cultural environment in which they occur. Recent articles in scientific¹ and lay² publications about the use of drugs by healthy people raised questions on the boundaries of our practice.

We need to distinguish between those pharmacological interventions which primarily count as 'therapies' and those which count as 'enhancements'. Therapies aim to treat, cure or prevent diseases; enhancements aim to improve normal skills. Drugs used to treat Attention Deficit/Hyperactivity Disorder (ADHD) may improve normal skills. That seems to be the case with stimulants such as methylphenidate. These drugs are also associated with diversion, abuse, dependence and sudden death.³ Although discussions about legalization of stimulants use in healthy people at first seemed restricted to the USA, this use is probably occurring also in Brazil. However, rigorous systematic research is lacking. This is still a matter of anecdotal cases in private offices. Some details were changed to prevent patient identification.

Case report: S. is a 21-year-old single woman who came to office asking for help to get a job. She applied for a selection process and asked for a prescription of methylphenidate to improve her chances. She became aware of this drug through a friend that was studying with her and reported an important improvement in academic test performance. The friend was using pills from his sister. S. had already taken this medication once, noticing a discrete improvement in her capabilities. There was no current or lifetime diagnosis of ADHD or any other psychiatric disorders. The performance in ASRS⁴ test was within the normal range. The risks and benefits of using stimulants in this manner were explained to her. General orientation about study, sleep, diet, leisure and relationships with others were highlighted. Methylphenidate was not prescribed. The patient seemed dissatisfied at the end of the appointment. A new appointment was scheduled, but the patient did not show up.

Discussion: Changing cultural values may put pressures on clinicians' decisions in order to prescribe performance enhancing drugs. We may be facing a paradigm shift towards Cosmetic Psychiatry. To go beyond therapy seems inevitable.⁵ Dermatology and plastic surgery have already changed. Society has evolved to accept the risks if the benefits are culturally valued. However, there are serious concerns; we don't know the risks of long term treatments both in patients and in healthy people.

The treatment of ADHD for all ages in the public health system in Brazil is far from ideal. Most patients do not receive any support. There has been an increased interest in using these drugs as enhancers in some social strata. We need to identify and define ethical issues raised by recent discussions and social pressures in order to anticipate and respond to clinical changes and public concerns. This may lead, where necessary, to the formulation of new guidelines or rules by the appropriate regulatory agencies.

Marcelo Victor

ADHD Outpatient Program – Adult Division, Hospital de

Clínicas de Porto Alegre (HCPA), Porto Alegre (RS), Brazil

• 1. Greely H, Sahakian B, Harris J, Kessler RC, Gazzaniga M, Campbell P, Farah MJ. Towards responsible use of cognitive-enhancing drugs by the healthy. Nature. 2008;456(7223):702-5. Erratum in: Nature. 2008;456(7224):872.
• 2. Smart drugs: Drugs to make you cleverer are in the test-tube. Good Economist. 2008;24 May:22.
• 3. Gould MS, Walsh BT, Munfakh JL, Kleinman M, Duan N, Olfson M, Greenhill L, Cooper T. Sudden death and use of stimulant medications in youths. Am J Psychiatry. 2009;166(9):992-1001.
• 4. Mattos P, Segenreich D, Saboya E, Louzã M, Dias G, Romano M. Transcultural adaptation of the adult self-report scale into Portuguese for evaluation of adult attention-deficit/hyperactivity disorder (ADHD). Rev Psiquiatr Clin. 2006;(33):188-94.
• 5. Chatterjee A. The promise and predicament of cosmetic neurology. J Med Ethics. 2006;32(2):110-3.

Publication Dates

• Publication in this collection
  22 Jan 2010
• Date of issue
  Dec 2009