Dealing with requests for pharmacological cognitive enhancement from healthy students

The use of drugs to enhance cognitive function and academic performance is clearly a global phenomenon, with the reported prevalence of stimulant use among medical students ranging from 15-20% (1, 2, 3). A multi-institution study from the USA reported a 6.9% lifetime prevalence of non-prescription use of cognitive enhancers among college students. A comprehensive systematic review indicates a 16–29% use of non-prescribed stimulants among all students for reasons that include increasing concentration and alertness. While mental health professionals and guidance counsellors anecdotally recall requests for pharmacological cognitive enhancement from otherwise healthy students, the exact magnitude of this problem in the Indian context is not clear.

The most frequently requested cognition-enhancing medications commercially available in India include methylphenidate, modafinil and caffeine. The pharmacological effectiveness of these agents is modest but notable in the domains of vigilance, concentration, working and episodic memory. However, the magnitude of benefit varies from individual to individual, with some studies reporting a deterioration in performance (4).

The long-term hazards, including the addiction potential of these agents, have not been well studied (5, 6). It is, therefore, challenging to parse the risks and benefits of these agents while having an informed discussion with one’s patients. While a physician and patient would be willing to risk adverse effects with medications provided with therapeutic intent, both parties would be more risk-averse in the domain of performance-enhancing medications (5). Further, a lack of awareness and knowledge of the use of these agents may also hamper us.

Prescribers face multiple ethical issues while prescribing cognitive enhancers (7). In an intensely competitive academic milieu, the use of these agents may be viewed as analogous to the use of performance-enhancing agents by elite athletes (4, 8). Is it fair that a student who has the information about these drugs and who has the ability to purchase them should have an advantage? If a student performs in a certain way while using cognitive enhancers, is the performance truly reflective of his/her capacity and who he/she is? Is it not analogous to the use of cosmetic surgery to win a beauty competition? However, it can be argued that the agents cannot create talent when none is present; they merely enhance that which is.

Increased awareness of the potential of these agents to improve performance in competitive examinations might expose vulnerable students to coercion. Vulnerable students might encounter pressure to use these agents from external parties with vested interests in their performance.

In summary, the answer to the original question of whether we should prescribe cognition-enhancing agents to healthy adults is a nebulous one, and can be heavily influenced by individual attitudes, awareness and ethics. More research and guidelines on the prescription of these agents is required, and is conspicuously lacking in the Indian context.