Medications for Cognitive Enhancement in the Healthy: Psychiatrists' Dilemma

Kate Johnson

October 01, 2010

October 1, 2010 (Toronto, Ontario) — Psychiatrists should be at the forefront of the debate about the nonmedicinal use of cognitive enhancement drugs because these products are already widely available without a prescription, says Derryck Smith, MD, clinical professor of psychiatry at the University of British Columbia, Vancouver, Canada.

"These medications are available now — people are buying them online or getting them from their friends, so we can't keep our heads in the sand," he told Medscape Medical News, after delivering a workshop on the subject at the Canadian Psychiatric Association (CPA) 60th Annual Conference.

I am absolutely fascinated that the neurologists are in this game before psychiatrists. Psychiatry should be at the forefront of this because these are medications that we all use on a regular basis.

"My position is they are better off being prescribed and monitored by doctors than being bought without a medical consultation."

The American Academy of Neurology (AAN) has endorsed "neuroenhancement," defined as the prescription of cognitive enhancement medications to healthy patients (Neurology. 2009;73:1406-1412), but to date, neither the CPA nor American Psychiatric Association have a stated position on this.

"I am absolutely fascinated that the neurologists are in this game before psychiatrists. I would think that psychiatry should be at the forefront of this because these are medications that we all use on a regular basis," he said during the workshop.

Ethical, Reasonable, Says AAN

In the absence of official guidelines, Dr. Smith believes psychiatrists should not hesitate to prescribe stimulants, such as dextroamphetamine sulfate, methylphenidate, or modafinil, for neuroenhancement if they wish.

These drugs have been shown to increase neurogenesis in the hippocampus and act on acetylcholine and nicotine neurotransmitters, he said (Pharmacol Res. 2008;57:196-214).

"We know they work, we know that many of these medications are very safe, we know that the American Academy of Neurology says it is ethical and reasonable to prescribe these if they're going to benefit patients, so psychiatrists are at liberty to use these medications as they see fit with fully informed patients," he said.

Studies indicate that cognitive enhancers improve memory, attention, and creativity, said Dr. Smith.

"Most of my patients have a medical indication — either ADHD [attention-deficit/hyperactivity disorder] or brain injury, but I think the effects of these medications are the same whether you have a medical diagnosis or not — they make everybody better."

Growing Demand

He noted a double-blind, random, crossover study in sleep-deprived emergency physicians that showed that modafinil improved sustained attention, cognitive control, working memory, and self-reported ability to attend lectures and learn (Acad Emerg Med. 2006;13:158-165).

"We're not talking about huge effect sizes; we're looking at effect sizes of 0.2 to 0.7, but studies do consistently show these kinds of improvements," he said, adding that he does not use the medications personally but is facing an increasing number of requests from patients.

"They're being widely used by a wide variety of different people — some of them quite clever people — university students, and researchers, and so on."

A recent Web survey of 3400 undergraduate students revealed a 5.4% prevalence of nonmedical stimulant use in the past 6 months (J Atten Disord. 2009;13:259-270), he said.

If you think about it, we don't seem to have any problem as a society or as a profession spending a lot of money making people's noses or breasts bigger or smaller. If we are prepared to sanction those kinds of medical interventions why would we want to have any sanctions on people who want to improve their cognitive functioning?

And a similar poll of 1400 scientists showed that 20% had used methylphenidate (62%) and/or modafinil (44%) for jet lag, to improve general concentration, or to assist them in a particular task (Nature. 2008;452:674-675).

In considering the ethics of prescribing neuroenhancers, Dr. Smith said that society endorses other drugs, such as caffeine and nicotine, both of which have proven benefits for memory and cognition.

"Neurogenesis also improves with exercise," he noted. "The idea that the brain is a static piece of equipment is long gone."

In addition, enhancement is accepted in other fields of medicine. "If you think about it, we don't seem to have any problem as a society or as a profession spending a lot of money making people's noses or breasts bigger or smaller. If we are prepared to sanction those kinds of medical interventions why would we want to have any sanctions on people who want to improve their cognitive functioning?"

Legal Restrictions Needed

There is some question whether cognitive enhancers actually work in healthy individuals, commented Daniel Saumier, PhD, a psychologist and assistant professor in the Department of Neurology and Neurosurgery at McGill University in Montreal, Quebec, Canada.

"Ritalin [methylphenidate], for instance, may help attention problems in individuals with ADHD, but there are other psychiatric populations who suffer from cognitive impairments, such as those with depression or schizophrenia, where there is a lack of well-controlled trials to determine whether cognitive enhancers are efficacious," he told Medscape Medical News.

"When studies do suggest that an enhancer may improve cognitive performance, they often involve small sample sizes and tasks, for example, computerized or paper and pencil tests, which are often difficult to generalize to the daily lives of individuals."

Dr. Saumier believes sale of cognitive enhancers should be restricted. "We have legal restrictions for the circulation of child pornography on the Internet, so why not impose similar constraints for the sale of such compounds?"

No one at either the CPA or American Psychiatric Association was available to comment.

Dr. Smith serves on advisory boards for Eli Lilly Canada Inc, Janssen-Ortho Inc, Purdue Pharmaceuticals, and Shire Canada Inc. Dr. Saumier is a former employee of Pfizer Canada Inc.

Canadian Psychiatric Association (CPA) 60th Annual Conference: Abstract W08. Presented September 24, 2010.

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