Professor Barbara Sahakian on neuroethics and the use of “smart drugs”.

by Raisa Ostapenko on 29 April 2015

“If you could legally obtain a pharmaceutical that would enhance your cognitive functions with no side effects, would you take it?”

To my surprise, a good number of audience members responded favourably. It was the fifth “Women of Achievement” lecture at Lucy Cavendish College, Cambridge. Our speaker was Dr. Barbara Sahakian, a professor of Clinical Neuropsychology in the Department of Psychiatry at the University of Cambridge, fellow of Clare Hall, and honorary clinical psychologist at Addenbrooke’s Hospital. Our topic was the use of “smart drugs” in the treatment of various mental disorders from ADHD to Schizophrenia and Alzheimer’s.

Dr. Sahakian is internationally acclaimed for her research on the early detection of neuropsychiatric disorders and on pharmacological treatments for cognitive enhancement. She is also a co-inventor of the Cambridge Neuropsychological Test Automated Battery (CANTAB) tests, which are now used at over 700 research institutes worldwide. Her main goal is to detect disorders early in order to give patients the most effective treatment possible, improve their functionality, and allow them to maintain regular lifestyles.

Early indicators of mental disorder can come in multiple forms. For instance, episodic memory problems, such as forgetting where you left your keys or where you parked your car, could be early signs of Alzheimer’s. Detection of biomarkers can also help to prevent the development of certain illnesses even before the appearance of symptoms.

According to Dr. Sahakian, 75% of all mental health disorders, including depression, start before the age of 24, with some studies suggesting that 50% start before the age of 14, which makes early detection and intervention all the more relevant. “Mental health promotion and mental illness prevention: The economic case” a 2011 study released by Personal Social Services Research Unit (PSSRU) researchers at the London School of Economics and Political Science, estimates the long-term cost-effectiveness of early assessment and treatment. For instance, in the case of persistent conduct disorders in children aged 5-10 years, “average potential savings from early intervention ... [are] estimated at £150,000 per case.”

These costs can fall both on the families of affected individuals and on the public sector. In the case of the latter, costs are “distributed across many agencies and are around ten times higher than [they are] for children with no conduct problems.” For more information, please see “Financial Cost of Social Exclusion: Follow-up Study of Antisocial Children into Adulthood”. 

Dr. Sahakian discussed various ideas, including that of neurogenisis, i.e. the generation of new brain cells, or neurons. Whilst neurogenesis is most active during pre-natal development, it continues throughout adulthood. Most mental disorders have been associated with a pronounced decrease in neurogenisis resulting from any number of factors, from genetics to chronic stress or aging. Another critical process is that of working memory, which plays a key in executive tasks such as reasoning, comprehension, and learning. Working memory is too compromised in mental disorder.

Cognitive enhancing drugs, also called smart drugs or nootropics, serve to improve one or more aspects of mental function, such as working memory or focus. Two substances that are used in the treatment of attention deficit hyperactivity disorder (ADHD) and narcolepsy, for instance, are methylphenidate (brand names include Ritalin and Concerta) and psychostimulant amphetamine/dextroamphetamine (popular brand name: Adderall). Norepinephrine reuptake inhibitor atomoxetine (brand name: Strattera) is used in the treatment of ADHD and improves response inhibition. Wakefulness-promoting agent modafinil (popular brand name: Provigil) is used in the treatment of narcolepsy and other sleep disorders and increases task-related motivation.

Many more pharmaceuticals of this type exist and a great number of them are used recreationally by healthy individuals to enhance cognitive abilities. It is estimated that 90% of Modafinil use is “off label”. According to Dr. Sahakian, there are even students at Cambridge who feel pressured to use cognitive enhancing drugs in order to “level the playing field” or to gain a competitive edge. Whether the goal is to get over jetlag or improve academic performance, the use of smart drugs by people without mental disorders is on the rise and has become an issue of great neuroethical controversy.

Generations of people have been able to secure Firsts or otherwise commendable degrees at Oxbridge without having to resort to the use of smart drugs. Yes, studying at elite universities is certainly not a walk in the park, but based on the performance of our predecessors, it can be argued that the workload is manageable, as long as you put in the effort, cultivate your mind, and actually get around to doing what is required of you. Is it, therefore, not safe to say that the artificial enhancement of intellectual performance is a form of cheating or an easy way out of a challenge that most of us took upon ourselves voluntarily?

Nevertheless, it can also be argued that smart drugs are but a more sophisticated means by which to increase efficiency, something that plenty of people strive to do on daily basis by indulging in naps, drinking coffee, or even popping caffeine pills, which happen to be legal and readily available at most pharmacies.

How do you grabble with such questions of neuroethics? More importantly, what does the relevance of this issue say about the state of our society? According to Dr. Sahakian, even teenagers are coerced to enhance their cognitive functions to improve performance at school. Researchers say that the human brain undergoes striking changes during adolescence – a crucial period of cognitive maturation. See “The Teen Brain: Still Under Construction” for more information. Is it sound to interfere with the functions of a brain that is still in development? Should schools perhaps educate students on the potential dangers of recreational nootropic use?

Additionally, research suggests that cognitive enhancing drugs can be additive in the doses taken by healthy individuals, because they bring about unnatural, fleeting states of euphoria (or “highs”) that individuals can subsequently start to crave. For this very reason, nootropics are sometimes even called gateway drugs to more serious substances such as cocaine or heroin. Addiction, however, seems to be rare in the therapeutic doses prescribed to individuals with mental disorders. It might also be possible that that long-term “off-label” use of nootropics can compromise individuals’ natural performance by encouraging a form of “neurological laziness,” though there have been no thorough studies on this question. Furthermore, cognitive enhancing pharmaceuticals are available only by prescription. Though anecdotal evidence suggests that some students purposefully “fail” cognitive tests in order to feign mental disorders such as ADHD and gain legal access to smart drugs, most people order these pharmaceuticals over the internet. Smart drugs websites are not legally certified to sell these substances and may even provide products that violate health regulations and can be toxic.

As it is, clinical trials have shown that cognitive enhancing drugs can bring about serious physiological consequences. For instance, there have been reports of atomoxetine-induced acute liver injury within 3-12 weeks of the start of treatment. Some of these cases required emergency liver transplantation. For more information, please see Livertox’s report on atomoxetine. Some of the other side effects of psychostimulants include, but are not limited to, aggression, changes in blood pressure, dizziness, drowsiness, hallucinations, headaches, heart palpitations, psychosis, and thoughts of suicide. For more information, please see Psychostimulants: The Facts about the Effects

Nevertheless, despite the evident risks involved in taking nootropics in non-therapeutic doses, researchers have suggested that the use of cognitive enhancing drugs to improve the performance of specific professionals, such as surgeons, bus drivers, and night shift workers, might not be a bad idea, granted that clinical trials prove that long-term use is safe in healthy people.

“Surgeons performing long, arduous operations remain susceptible to the effects of fatigue, and frequent transitions from day to night work expose junior doctors to the risk of impaired psychomotor performance,” Dr. Sahakian wrote in a 2011 article called “The Ethics of Smart Drugs.” ... “Indeed, fatigued doctors risk making poor judgements and committing serious medical errors … pharmacological methods could conceivably be used to combat fatigue at some time in the future.”

Raisa Ostapenko (2014) M Phil (Modern European History)

Photo credits: Anastasia Kozlovtseva

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