This article was downloaded by: [Michigan State University] On: 13 February 2015, At: 22:02 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20
Cognitive Enhancement in Canadian Medical Students a
Paul A. Kudlow M.D. B.Sc. , Karline Treurnicht Naylor B.Sc. McIntyre M.D. F.R.C.P.C.
b c
d
, Bin Xie Ph.D. & Roger S.
e
a
Department of Psychiatry , University of Toronto , Toronto , Canada
b
Columbia University , New York , NY
c
Schulich School of Medicine and Dentistry , University of Western Ontario , London , Canada d
Department of Obstetrics and Gynecology and the Department of Epidemiology and Biostatistics , University of Western Ontario , London , Canada e
Psychiatry and Pharmacology , University of Toronto, Head, Mood Disorders Psychopharmacology Unit, University Health Network , Toronto , Canada Published online: 27 Sep 2013.
To cite this article: Paul A. Kudlow M.D. B.Sc. , Karline Treurnicht Naylor B.Sc. , Bin Xie Ph.D. & Roger S. McIntyre M.D. F.R.C.P.C. (2013) Cognitive Enhancement in Canadian Medical Students, Journal of Psychoactive Drugs, 45:4, 360-365, DOI: 10.1080/02791072.2013.825033 To link to this article: http://dx.doi.org/10.1080/02791072.2013.825033
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Journal of Psychoactive Drugs, 45 (4), 360–365, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 0279-1072 print / 2159-9777 online DOI: 10.1080/02791072.2013.825033
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Cognitive Enhancement in Canadian Medical Students Paul A. Kudlow, M.D., B.Sc.a ; Karline Treurnicht Naylor, B.Sc.b,c ; Bin Xie, Ph.D.d & Roger S. McIntyre, M.D., F.R.C.P.C.e
Abstract — Background: Cognitive enhancing agents are substances that may augment functions such as memory, attention, concentration, wakefulness, and intelligence. Methods: An anonymous, online survey containing a series of questions on the actual and hypothetical use of cognitive enhancers was sent via email to 647 medical students across all four years in one Canadian MD program. Results: The response rate was 50% (326/647). Overall, 49 (15%, 95% CI: 11% to19%) students admitted to non-medical and/or off-label use of one or more pharmaceutical stimulants, of whom 14 (4%, 95% CI: 2% to 6%) had used stimulants within the last year. Senior medical students reported recent use more often than junior students (8% vs. 2%, P = 0.04). Class seniority and male gender were both associated with positive attitudes towards use of these agents; favorable attitudes were associated with recent use of pharmaceutical stimulant and high-caffeine products. Conclusion: A substantial proportion of Canadian medical students have engaged at some point in non-medical and/or off-label use of stimulants for purposes of cognitive enhancement. Male students and those in upper years of the MD program were more likely to have used pharmaceutical stimulants in the last year, and have favorable attitudes concerning use of cognitive-enhancing agents. Keywords — cognitive enhancers, medical students, modafinil, off-label use, prevalence, Ritalin
INTRODUCTION Cognitive enhancement has been defined as the ingestion of substances by healthy individuals to augment mental functions such as memory, attention, concentration, wakefulness, and/or intelligence (Chatterjee 2004). A list of commonly used cognitive enhancers can be
found in Table 1. During the past decade, substantial attention has been paid to the increasing rates of use in non-medical populations of a variety of agents with putative cognitive-enhancing properties (Greely et al. 2008; Sahakian & Morein Zamir 2007; McCabe et al. 2005). The debate around cognitive enhancement has primarily focused on pharmaceutical stimulants such as
We would like to thank Dr. Verinder Sharma and Dr. Heather Boon for their assistance with statistical analysis and study design, respectively. Paul A. Kudlow, Karline Treurnicht Naylor, and Bin Xie declare no conflict of interests. Dr. Roger McIntyre has received research funding from AstraZeneca, GlaxoSmithKline, Merck, Servier, and Wyeth and has served as a consultant to and on the speaker’s boards for AstraZeneca, Eli Lilly, GlaxoSmithKline, Lundbeck, Organon, Ortho-McNeil-Janssen, Oryx, Pfizer, Prestwick, and Wyeth. All authors received no direct support from any organization for the submitted work. a Psychiatry Resident, Department of Psychiatry, University of Toronto, Toronto, Canada. b MPH Candidate, Columbia University, New York, NY.
c M.D. Candidate, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada. d Assistant Professor in the Department of Obstetrics and Gynecology and the Department of Epidemiology and Biostatistics at the University of Western Ontario, London, Canada. e Professor of Psychiatry and Pharmacology, University of Toronto, Head, Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Canada. Please address correspondence to Paul A. Kudlow, Psychiatry Resident in the Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON M5T 2S8, Canada; email: [email protected]
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TABLE 1 Commonly Encountered Cognitive Enhancers Substance Caffeine
Indicated Use 90% of North Americans consume daily. Available in a variety of formulations (e.g., coffee, tea, Coca Cola, etc.) (Reissig, Strain, & Griffiths 2009; Hughes & Oliveto 1997). Enhances alertness and focus (Nehlig, Daval & Debry 1992).
Mechanism of Action Non-selective adenosine receptor antagonist. This leads to increases in dopamine, glutamate norepinephrine, acetylcholine and, to a lesser extent, serotonin (Fisone, Borgkvist & Usiello 2004).
Common side-effects Dose dependent. Moderate to high doses can induce nervousness, irritability, restlessness, insomnia, headaches, frequent urination, heart palpitations, dependency, addiction (Killgore et al. 2008; Shapiro 2008).
Methylphenidate (Ritalin), dextroamphetamine (Dexedrine), dextro/ levoamphetamine (Adderall)
Psychostimulant drug approved for the treatment of attention-deficit hyperactivity disorder (ADHD), postural orthostatic tachycardia syndrome, and narcolepsy. Enhances alertness, focus, and memory (Lynch, Palmer & Gall, 2011; Repantis et al. 2010).
Increases levels of norepinephrine and dopamine through reuptake inhibition (Repantis et al. 2010).
Dose dependent. Typically include nervousness and insomnia. In some, and at higher doses, abdominal pain, headache, euphoria, angina, cardiac arrhythmias, blurred vision. Other side-effects are possible, but very rare. Risk of misuse and abuse (Repantis et al. 2010).
Modafinil (Provigil), adrafanil (Olmifon)
Non-amphetamine, “wakefulness promoting agent,” approved for the treatment of excessive sleepiness associated with narcolepsy, obstructive sleep apnoea, and shift work sleep disorder. Enhances alertness and focus (Minzenberg & Carter 2008; Czeisler et al. 2005).
Mechanism of action not fully understood. Has been shown to have effects on catecholamines, serotonin, glutamate, gamma amino-butyric acid, orexin, and histamine systems in the brain (Minzenberg & Carter 2008).
Dose dependent. >10% report headache and/nausea. Less common side-effects include chest pain, hypertension, nervousness, and dermatologic reactions (Repantis et al. 2010; Czeisler et al. 2005).
amphetamines and the new, non-amphetamine wakefulness agent, modafinil. However, caffeine has long been used to enhance alertness and attention. Based on survey data, it has been estimated that 90% of North Americans consume caffeine daily (Hughes & Oliveto 1997). While most caffeine intake involves consumption of coffee and tea, the use of heavily caffeinated drinks (e.g., “Red Bull”) continues to rise. In 2006, annual worldwide energy drink consumption increased 17% from the previous year to 906 million gallons, with the U.S. leading the world in total volume sales (Reissig, Strain & Griffiths 2009). As well, in a sample of 10,904 American college students, the lifetime prevalence of a non-medical pharmaceutical stimulant (Ritalin, Dexedrine, or Adderall) use was 6.9% (McCabe et al. 2005). Other student populations have reported similar percentages ranging from 2 to 25% (McCabe et al. 2005). An unofficial online survey conducted by Nature reported that 20% of the
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1400 respondents (from 60 countries) admitted to offlabel use of pharmaceutical stimulants for the purpose of cognitive enhancement (Maher 2008). However, the use of these substances among physicians—students, trainees, or practitioners—has received only limited attention in the academic literature (Webb, Thomas & Valasek 2010; Bergstrom & Lynoe 2008). Evidence from college populations indicates that usage of cognitive enhancers, particularly of pharmaceutical stimulants and highly caffeinated energy drinks, is a proxy for student pressure to perform and has been shown to be strongly associated with the use of illicit drugs and other risky behaviors (McCabe et al. 2005). Healthcare practitioners also experience high demands and pressures to perform. We hypothesize that healthcare practitioners may be a high-risk population that deserves study. The prevalence of cognitive enhancement behaviors amongst Canadian medical students has not yet been
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TABLE 2 Prevalence Data
Substance group Coffee, tea, cola High-caffeine energy beverages Natural supplements (i.e., gingko biloba, omega 3 fatty acids, B vitamins, melatonin, choline) Tobacco, decongestants Stimulant pharmaceuticals (i.e., methylphenidate, modafinil, dextroamphetamine, dextro/ levoamphetamine, adrafanil, piracetam )
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∗ All
Lifetime use 300 (92%, ∗ CI: 89%–95%) 169 (52%, CI: 47%–57%) 97 (30%, CI: 25%–35%)
Use within the last year (recent use) 271 (83%, CI: 79%–87%) 82 (25%, CI: 20%–30%) 62 (19%, CI: 15%–23%)
39 (12%, CI: 8%–15%) 49 (15%, CI: 11%–19%)
8 (2%, CI: 0.2%–4%) 14 (4%, CI: 2%–6%)
95% CI.
examined. This study aims to assess the actual and hypothetical use of cognitive enhancers in a sample of Canadian medical students.
was approved by regulatory authorities, and was devoid of significant side-effects. The drugs were indicated for differing aspects of cognition: alertness and wakefulness; concentration and focus; and learning and memory. We asked participants to rate whether they would ingest the drug, on a five-point scale; response categories were absolutely not, not likely, unsure, likely, or absolutely. If a participant responded with “unsure,” “not likely,” or “absolutely not” regarding ingestion of the drug, they were prompted to select from a list of reasons for avoidance. Participants were also given the option to enter their own reason for avoidance if the given list did not include it. A similar series of vignettes were utilized for another question, describing three new non-pharmacological, “natural supplement” cognitive enhancers. Participants were again asked to rate the likelihood that they would use the substance, as described above. Characteristics of the study participants were obtained from the frequency of responses. The statistical significance of the associations between predictors and outcome variables, as well as those between different outcome variables, was tested using Chi-square tests or Fisher’s exact tests. All analyses were performed using statistical software R V2.14.0 (http://cran.r-project.org/bin/windows/ base/old/2.14.0)
METHODS An anonymous, online survey consisting of eight multi-step questions (i.e., respondents were asked to fill in a chart similar to Table 2) concerning actual and hypothetical use of cognitive enhancers was sent out via e-mail to 647 medical students across all four years. A copy of the survey can be found at http://sgiz.mobi/s3/Cognitiveenhancement-in-Canadian-medical-students-a-nationalsurvey. Respondents attended a Canadian medical school (year 1 (n = 171); year 2 (n = 169); year 3 (n = 159); and year 4 (n = 148)). The data for the survey were collected between September and November 2011. Prior to wide release, the survey was piloted with a group of five medical students and an expert evaluator (see acknowledgements) and no ambiguities were identified. This study received approval from the university’s Research Ethics Board. The survey collected demographic data, including date of birth, gender, year of study, and highest level of parental education. Following this, the survey included a page of background information, where we stated the goal of the survey and provided the definition of a “cognitive enhancer” (i.e., the same definition used in the introduction). Participants were also asked to complete a chart containing a list of various cognitive enhancers they may have used (Table 2). Participants were asked not to fill in anything they took for purposes other than for cognitive enhancement, and to exclude anything taken on the advice of a prescribing professional. To assess attitudes towards the use of cognitive enhancers, we presented a series of vignettes describing the creation of three new pharmacological cognitive enhancers. Participants were told that each drug had proven efficacy,
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RESULTS Of the 647 medical students surveyed, 326 responded (50%). Male and female students were approximately equally distributed (51% M, 49% F), with no statistical differences between our sample and the class distribution (P = 0.54). Respondents included 192/340 (56%) junior students (from years 1 and 2), and 134/307 (44%) senior students (from years 3 and 4). There were no statistical differences between the distribution of our sample and the
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TABLE 3 Prevalence of recent use by attitudes towards hypothetical cognitive (alertness and wakefulness) enhancer use
Negative attitudes Neutral attitudes Positive attitudes
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∗ p-values
Coffee, tea, cola 98 p = 0.09 51 p = 0.44 118 p = 0.29
High-caffeine energy beverages 17 p < 0.01 10 p = 0.15 54 p < 0.01
Natural supplements 12 p < 0.01 12 p = 0.91 36 p < 0.01
Tobacco, decongestants 3 p = 0.74 2 p = 0.96 3 p = 0.94
Stimulant pharmaceuticals 1 p = 0.03 1 p = 0.46 12 p < 0.01
calculated based on chi-square statistics with one degree of freedom.
distribution of the actual class population, with regards to junior versus senior students (P = 0.066). As shown in Table 2, the lifetime prevalence of caffeine use (in the form of coffee, tea, or soda) was 92% (95% CI: 89% to 95%). One hundred and sixty-nine (52%, 95% CI: 47% to 57%) students admitted to the use of highcaffeine products, including high-caffeine energy drinks (e.g., “Red Bull”) and caffeine pills, for the purposes of enhancement. Male students were more likely to use highcaffeine products than female students (63% vs. 40%, P < 0.01), and senior medical students were more likely to use high-caffeine products than junior students (59% vs. 47%, P = 0.03). High-caffeine use was strongly associated with the use of stimulant substances (P < 0.01). Of the 49 (15%, 95% CI: 11% to 19%) students who admitted to off-label use of one or more pharmaceutical stimulants for cognitive enhancement (lifetime prevalence), 14 (4%, 95% CI: 2% to 6%) students had used stimulants within the last year (Table 2). The number of substances ingested by students, in order of reported lifetime prevalence, includes methylphenidate (Ritalin) (24 [7%]), modafinil (Provigil) (18 [6%]), dextroamphetamine (Dexedrine) (11 [3%]), dextro/levoamphetamine (Adderall) (10 [3%]), adrafanil (Olmifon) (5 [2%]), and piracetam (5 [2%]). Senior medical students were more likely than junior students to report use of stimulant substances within the past year (8% vs. 2%, P = 0.04). Attitudes and self-reported actions aligned. Male students (80 [53%]) were more likely than female students (49 [33%]) to have positive attitudes towards the use of a hypothetical cognitive enhancer indicated for alertness and wakefulness (p < 0.01). Compared with junior medical students (61 [35%]), senior medical students (67 [53%]) were also more likely to have positive attitudes towards the use of a hypothetical cognitive enhancer indicated for alertness and wakefulness (p < 0.01). No statistical differences in attitudes were found between agents indicated for alertness and wakefulness, concentration and focus, and learning and memory. Compared to medical students with negative and neutral attitudes towards cognitive enhancement, Journal of Psychoactive Drugs
those with favorable attitudes were more likely to use pharmaceutical stimulants (12 [86%], p < 0.01) and highcaffeine products (54 [66%], p < 0.01) within the last year (Table 3). We found no statistical differences between attitudes towards pharmacological or natural supplements. The most common reasons for avoidance were concerns regarding safety, dependency, and preservation of self-efficacy.
DISCUSSION This survey showed that 15% of medical students in the sampled Canadian institution reported non-medical and/or off-label use of pharmaceutical stimulants at some point in their life, and 52% admitted to use of high-caffeine products for the purposes of cognitive enhancement. A survey of American medical students found a prevalence of 10.1% for lifetime non-medical pharmaceutical stimulant use (methyphenidate or amphetamine salts) (Tuttle, Scheurich & Ranseen 2010). A similar study in a sample of American dental students found a 12.4% prevalence of pharmaceutical stimulant use (with the majority of use for cognitive-enhancement purposes) (McNiel et al. 2011). These results suggest that the use of cognitive enhancers in a healthcare student setting is higher than use among general student populations (6.9%) (McCabe et al. 2005). Increased use of cognitive enhancers in this population may be fuelled by increased levels of knowledge around the availability and utility of these substances. This, along with levels of stress (Dyrbye et al. 2006; Dyrbye, Thomas & Huntington 2006) and on-call hours, may help explain the association between year of medical study and recent use of pharmaceutical stimulants. Higher use and more positive attitudes among male students may reflect sex differences in risk-taking behavior. Non-medical pharmaceutical stimulant users, as well as those that use high-caffeine energy drinks (e.g., “Red Bull”), have been found to be more sensation-seeking, and exhibit traits of perfectionism (Low & Gendaszek 2002). 363
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They are significantly more likely to report use of alcohol, cigarettes, marijuana, ecstasy, cocaine, and engage in other risky behaviors (Arria, Caldeira & Kasperski 2010; Malinauskas, Aeby & Overton 2007; McCabe et al. 2005; Teter et al. 2005; Hughes & Olivetto 1997). This suggests that users of cognitive enhancers may be a high-risk population for substance abuse and/or mental health issues more generally. More research is necessary to determine whether the use of cognitive enhancers per se warrants intervention. These attitudes and behaviors have several implications. First, the personal use of cognitive enhancers, particularly pharmaceutical stimulants, in a clinical environment may have a direct impact on patient care, including a lower threshold for prescribing psycho-active medications (Banjo, Nadler & Reiner 2010). The use of cognitive enhancers may also be indicative of users’ failure to cope with academic or workplace demands, and be a marker for risk of later substance abuse—a particular concern given physicians’ ready access to psycho-active drugs, intrinsic job stresses, and the consequences of such substance abuse for patient safety. As it stands, up to 10% to 15% of all physicians will misuse drugs at some point during their career. It is estimated that 6% to 8% of physicians can be classified as having a substance use disorder, and the rates of use of certain drugs, including opiates and benzodiazepines, have been reported to be five times higher than rates in the general population (Balidisseri 2007). The implications of the self-reported use of high-dose caffeine substances are less clear, given the widespread consumption of caffeine worldwide. Nonetheless, studies have shown that both members of the general population and physicians are uncomfortable with the enhancement of cognition through pharmaceuticals (Bergstrom & Lynoe 2008; Malinauskas, Aeby & Overton 2007). In one such study, both general practitioners and the general public indicated that the use of natural remedies for cognitive enhancement was more acceptable than the use of pharmaceuticals (Bergstrom & Lynoe 2008). This finding aligns
with our survey results, wherein lifetime use of natural supplements for cognitive enhancement was twice as prevalent as that of pharmaceutical stimulants. Our survey also confirmed results from other studies that elucidated reasons for avoidance of cognitive enhancement (Bergstrom & Lynoe 2008); the most commonly cited reasons among those who denied use of cognitive enhancers were concerns regarding safety, dependency, and preservation of self-efficacy. A key limitation of this study is that it was carried out at a single institution; however, we have no reason to believe that the results are not generalizable to students studying elsewhere. While self-selection may have led to a positive response bias, it is equally plausible that non-respondents did not wish to disclose use of cognitive enhancers. It is possible that students misread the survey instructions and included substances taken on medical advice. Finally, the survey was sent out between September and November 2011, and these behaviors may fluctuate with stressors during the academic cycle.
CONCLUSION This study is the first to examine cognitive enhancement attitudes and behaviors in a sample of Canadian medical students. A surprising proportion of Canadian medical students in this sample engaged in non-medical and/or offlabel use of pharmaceutical stimulants and other substances for the purposes of cognitive enhancement. We do not know if these attitudes and behaviors are associated positively or negatively with clinical competency and, despite suggestive evidence from other populations, a relationship to later substance abuse remains hypothetical. Furthermore, students’ point of access to non-medical pharmaceutical stimulants remains unclear. All of these issues warrant further study, along with continuing attention to the academic and occupational stressors that might be leading to use of stimulants and so-called cognitive enhancers during medical training.
REFERENCES Czeisler, C.; Walsh, J.K.; Roth, T.; Hughes, R.J.; Wright, K.P.; Kingsbury, L.; Arora, S.; Schwartz, J.R.; Niebler, G.E. & Dinges, D.F. 2005. Modafinil for excessive sleepiness associated with shift-work sleep disorder. New England Journal of Medicine 353 (5): 476–86. Dyrbye, L.N.; Thomas, M.R. & Huntington, J.L. 2006. Personal life events and medical student burnout: A multicenter study. Academic Medicine 81: 374–84. Dyrbye, L.N.; Thomas, M.R. & Shanafelt, T.D. 2006. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic Medicine 81 (4): 354–73. Fisone, G.; Borgkvist, A. & Usiello, A. 2004. Caffeine as a psychomotor stimulant: Mechanism of action. Cell and Molecular Life Sciences 61 (7–8): 857–72. Greely, H.; Sahakian, B.; Harris, J.; Kessler, R.C.; Gazzaniga, M.; Campbell, P. & Farah, M.J. 2008. Towards responsible use of
Arria, A.M.; Caldeira, K.M. & Kasperski, S.J. 2010. Increased alcohol consumption, nonmedical prescription drug use, and illicit drug use are associated with energy drink consumption among college students. Journal of Addiction Medicine 4 (2): 74–80. Baldisseri, M.R. 2007. Impaired healthcare professional. Critical Care Medicine 35 (2 Suppl): S106–16. Banjo, O.C.; Nadler, R. & Reiner, P.B. 2010. Physician attitudes towards pharmacological cognitive enhancement: Safety concerns are paramount. PLoS One 5 (12): e14322. Bergström, L.S. & Lynöe, N. 2008. Enhancing concentration, mood and memory in healthy individuals: An empirical study of attitudes among general practitioners and the general population. Scandinavian Journal of Public Health 36 (5): 532–7. Chatterjee, A. 2004. Cosmetic neurology: The controversy over enhancing movement, mentation, and mood. Neurology 63 (6): 968–74. Journal of Psychoactive Drugs
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Downloaded by [Michigan State University] at 22:02 13 February 2015
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Minzenberg, M.J. & Carter, C.S. 2008. Modafinil: A review of neurochemical actions and effects on cognition. Neuropsychopharmacology : Official Publication of the American College of Neuropsychopharmacology 33 (7): 1477–502. Nehlig, A.; Daval, J.L. & Debry, G. 1992. Caffeine and the central nervous system: Mechanisms of action, biochemical, metabolic and psychostimulant effects. Brain Research. Brain Research Reviews 17 (2): 139–70. Repantis, D.; Schlattmann, P.; Laisney, O. & Heuser, I. 2010. Modafinil and methylphenidate for neuroenhancement in healthy individuals: A systematic review. Pharmacological Research : The Official Journal of the Italian Pharmacological Society 62 (3): 187–206. Reissig, C.J.; Strain, E.C. & Griffiths, R.R. 2009. Caffeinated energy drinks: A growing problem. Drug and Alcohol Dependence 99 (1–3): 1–10. Sahakian, B. & Morein-Zamir, S. 2007. Professor’s little helper. Nature 450 (7173): 1157–1159. Shapiro, R.E. 2008. Caffeine and headaches. Current Pain and Headache Reports 12 (4): 311–315. Teter, C.J.; McCabe, S.E.; Cranford, J.A.; Boyd, C.J. & Guthrie, S.K. 2005. Prevalence and motives for illicit use of prescription stimulants in an undergraduate student sample. The Journal of American College Health 53 (6): 253–62. Tuttle, J.P.; Scheurich, N.E. & Ranseen, J. 2010. Prevalence of ADHD diagnosis and nonmedical prescription stimulant use in medical students. Academic Psychiatry 34 (3): 220–3. Webb, J.R.; Thomas, J.W. & Valasek, M.A. 2010. Contemplating cognitive enhancement in medical students and residents. Perspectives in Biology and Medicine 53 (2): 200–14.
cognitive-enhancing drugs by the healthy. Nature 456 (7223): 702–5. Erratum in Nature 2008 Dec 18; 456 (7224): 872. Hughes, J.R. & Oliveto, A.H. 1997. A systematic survey of caffeine intake in Vermont. Experimental and Clinical Psychopharmacoly 5: 393–398. Killgore, W.D.; Rupp, T.L.; Grugle, N.L.; Reichardt, R.M.; Lipizzi, E.L. & Balkin, T.J. 2008. Effects of dextroamphetamine, caffeine and modafinil on psychomotor vigilance test performance after 44 h of continuous wakefulness. Journal of Sleep Research 17 (3): 309–321. Low, K.G. & Gendaszek, A.E. 2002. Illicit use of psychostimulants among college students: A preliminary study. Psychology, Health & Medicine 7 (3): 283–87. Lynch, G.; Palmer, L.C. & Gall, C.M. 2011. The likelihood of cognitive enhancement. Pharmacology, Biochemistry, and Behavior 99 (2): 116–29. Maher, B. 2008. Poll results: Look who’s doping. Nature 452 (7188): 674–5. Malinauskas, B.M.; Aeby, V.G. & Overton, R.F. 2007. A survey of energy drink consumption patterns among college students. Nutrition Journal 6: 35. McCabe, S.E.; Knight, J.R.; Teter, C.J. & Wechsler, H. 2005. Nonmedical use of prescription stimulants among US college students: Prevalence and correlates from a national survey. Addiction 100 (1): 96–106. Erratum in Addiction 2005 Apr; 100 (4): 573. McNiel, A.D.; Muzzin, K.B.; DeWald, J.P.; McCann, A.L.; Schneiderman, E.D.; Scofield, J. & Campbell, P.R. 2011.The nonmedical use of prescription stimulants among dental and dental hygiene students. Journal of Dental Education 75 (3): 365–76.
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Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20
Cognitive Enhancement in Canadian Medical Students a
Paul A. Kudlow M.D. B.Sc. , Karline Treurnicht Naylor B.Sc. McIntyre M.D. F.R.C.P.C.
b c
d
, Bin Xie Ph.D. & Roger S.
e
a
Department of Psychiatry , University of Toronto , Toronto , Canada
b
Columbia University , New York , NY
c
Schulich School of Medicine and Dentistry , University of Western Ontario , London , Canada d
Department of Obstetrics and Gynecology and the Department of Epidemiology and Biostatistics , University of Western Ontario , London , Canada e
Psychiatry and Pharmacology , University of Toronto, Head, Mood Disorders Psychopharmacology Unit, University Health Network , Toronto , Canada Published online: 27 Sep 2013.
To cite this article: Paul A. Kudlow M.D. B.Sc. , Karline Treurnicht Naylor B.Sc. , Bin Xie Ph.D. & Roger S. McIntyre M.D. F.R.C.P.C. (2013) Cognitive Enhancement in Canadian Medical Students, Journal of Psychoactive Drugs, 45:4, 360-365, DOI: 10.1080/02791072.2013.825033 To link to this article: http://dx.doi.org/10.1080/02791072.2013.825033
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Cognitive Enhancement in Canadian Medical Students Paul A. Kudlow, M.D., B.Sc.a ; Karline Treurnicht Naylor, B.Sc.b,c ; Bin Xie, Ph.D.d & Roger S. McIntyre, M.D., F.R.C.P.C.e
Abstract — Background: Cognitive enhancing agents are substances that may augment functions such as memory, attention, concentration, wakefulness, and intelligence. Methods: An anonymous, online survey containing a series of questions on the actual and hypothetical use of cognitive enhancers was sent via email to 647 medical students across all four years in one Canadian MD program. Results: The response rate was 50% (326/647). Overall, 49 (15%, 95% CI: 11% to19%) students admitted to non-medical and/or off-label use of one or more pharmaceutical stimulants, of whom 14 (4%, 95% CI: 2% to 6%) had used stimulants within the last year. Senior medical students reported recent use more often than junior students (8% vs. 2%, P = 0.04). Class seniority and male gender were both associated with positive attitudes towards use of these agents; favorable attitudes were associated with recent use of pharmaceutical stimulant and high-caffeine products. Conclusion: A substantial proportion of Canadian medical students have engaged at some point in non-medical and/or off-label use of stimulants for purposes of cognitive enhancement. Male students and those in upper years of the MD program were more likely to have used pharmaceutical stimulants in the last year, and have favorable attitudes concerning use of cognitive-enhancing agents. Keywords — cognitive enhancers, medical students, modafinil, off-label use, prevalence, Ritalin
INTRODUCTION Cognitive enhancement has been defined as the ingestion of substances by healthy individuals to augment mental functions such as memory, attention, concentration, wakefulness, and/or intelligence (Chatterjee 2004). A list of commonly used cognitive enhancers can be
found in Table 1. During the past decade, substantial attention has been paid to the increasing rates of use in non-medical populations of a variety of agents with putative cognitive-enhancing properties (Greely et al. 2008; Sahakian & Morein Zamir 2007; McCabe et al. 2005). The debate around cognitive enhancement has primarily focused on pharmaceutical stimulants such as
We would like to thank Dr. Verinder Sharma and Dr. Heather Boon for their assistance with statistical analysis and study design, respectively. Paul A. Kudlow, Karline Treurnicht Naylor, and Bin Xie declare no conflict of interests. Dr. Roger McIntyre has received research funding from AstraZeneca, GlaxoSmithKline, Merck, Servier, and Wyeth and has served as a consultant to and on the speaker’s boards for AstraZeneca, Eli Lilly, GlaxoSmithKline, Lundbeck, Organon, Ortho-McNeil-Janssen, Oryx, Pfizer, Prestwick, and Wyeth. All authors received no direct support from any organization for the submitted work. a Psychiatry Resident, Department of Psychiatry, University of Toronto, Toronto, Canada. b MPH Candidate, Columbia University, New York, NY.
c M.D. Candidate, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada. d Assistant Professor in the Department of Obstetrics and Gynecology and the Department of Epidemiology and Biostatistics at the University of Western Ontario, London, Canada. e Professor of Psychiatry and Pharmacology, University of Toronto, Head, Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Canada. Please address correspondence to Paul A. Kudlow, Psychiatry Resident in the Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON M5T 2S8, Canada; email: [email protected]
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TABLE 1 Commonly Encountered Cognitive Enhancers Substance Caffeine
Indicated Use 90% of North Americans consume daily. Available in a variety of formulations (e.g., coffee, tea, Coca Cola, etc.) (Reissig, Strain, & Griffiths 2009; Hughes & Oliveto 1997). Enhances alertness and focus (Nehlig, Daval & Debry 1992).
Mechanism of Action Non-selective adenosine receptor antagonist. This leads to increases in dopamine, glutamate norepinephrine, acetylcholine and, to a lesser extent, serotonin (Fisone, Borgkvist & Usiello 2004).
Common side-effects Dose dependent. Moderate to high doses can induce nervousness, irritability, restlessness, insomnia, headaches, frequent urination, heart palpitations, dependency, addiction (Killgore et al. 2008; Shapiro 2008).
Methylphenidate (Ritalin), dextroamphetamine (Dexedrine), dextro/ levoamphetamine (Adderall)
Psychostimulant drug approved for the treatment of attention-deficit hyperactivity disorder (ADHD), postural orthostatic tachycardia syndrome, and narcolepsy. Enhances alertness, focus, and memory (Lynch, Palmer & Gall, 2011; Repantis et al. 2010).
Increases levels of norepinephrine and dopamine through reuptake inhibition (Repantis et al. 2010).
Dose dependent. Typically include nervousness and insomnia. In some, and at higher doses, abdominal pain, headache, euphoria, angina, cardiac arrhythmias, blurred vision. Other side-effects are possible, but very rare. Risk of misuse and abuse (Repantis et al. 2010).
Modafinil (Provigil), adrafanil (Olmifon)
Non-amphetamine, “wakefulness promoting agent,” approved for the treatment of excessive sleepiness associated with narcolepsy, obstructive sleep apnoea, and shift work sleep disorder. Enhances alertness and focus (Minzenberg & Carter 2008; Czeisler et al. 2005).
Mechanism of action not fully understood. Has been shown to have effects on catecholamines, serotonin, glutamate, gamma amino-butyric acid, orexin, and histamine systems in the brain (Minzenberg & Carter 2008).
Dose dependent. >10% report headache and/nausea. Less common side-effects include chest pain, hypertension, nervousness, and dermatologic reactions (Repantis et al. 2010; Czeisler et al. 2005).
amphetamines and the new, non-amphetamine wakefulness agent, modafinil. However, caffeine has long been used to enhance alertness and attention. Based on survey data, it has been estimated that 90% of North Americans consume caffeine daily (Hughes & Oliveto 1997). While most caffeine intake involves consumption of coffee and tea, the use of heavily caffeinated drinks (e.g., “Red Bull”) continues to rise. In 2006, annual worldwide energy drink consumption increased 17% from the previous year to 906 million gallons, with the U.S. leading the world in total volume sales (Reissig, Strain & Griffiths 2009). As well, in a sample of 10,904 American college students, the lifetime prevalence of a non-medical pharmaceutical stimulant (Ritalin, Dexedrine, or Adderall) use was 6.9% (McCabe et al. 2005). Other student populations have reported similar percentages ranging from 2 to 25% (McCabe et al. 2005). An unofficial online survey conducted by Nature reported that 20% of the
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1400 respondents (from 60 countries) admitted to offlabel use of pharmaceutical stimulants for the purpose of cognitive enhancement (Maher 2008). However, the use of these substances among physicians—students, trainees, or practitioners—has received only limited attention in the academic literature (Webb, Thomas & Valasek 2010; Bergstrom & Lynoe 2008). Evidence from college populations indicates that usage of cognitive enhancers, particularly of pharmaceutical stimulants and highly caffeinated energy drinks, is a proxy for student pressure to perform and has been shown to be strongly associated with the use of illicit drugs and other risky behaviors (McCabe et al. 2005). Healthcare practitioners also experience high demands and pressures to perform. We hypothesize that healthcare practitioners may be a high-risk population that deserves study. The prevalence of cognitive enhancement behaviors amongst Canadian medical students has not yet been
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TABLE 2 Prevalence Data
Substance group Coffee, tea, cola High-caffeine energy beverages Natural supplements (i.e., gingko biloba, omega 3 fatty acids, B vitamins, melatonin, choline) Tobacco, decongestants Stimulant pharmaceuticals (i.e., methylphenidate, modafinil, dextroamphetamine, dextro/ levoamphetamine, adrafanil, piracetam )
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∗ All
Lifetime use 300 (92%, ∗ CI: 89%–95%) 169 (52%, CI: 47%–57%) 97 (30%, CI: 25%–35%)
Use within the last year (recent use) 271 (83%, CI: 79%–87%) 82 (25%, CI: 20%–30%) 62 (19%, CI: 15%–23%)
39 (12%, CI: 8%–15%) 49 (15%, CI: 11%–19%)
8 (2%, CI: 0.2%–4%) 14 (4%, CI: 2%–6%)
95% CI.
examined. This study aims to assess the actual and hypothetical use of cognitive enhancers in a sample of Canadian medical students.
was approved by regulatory authorities, and was devoid of significant side-effects. The drugs were indicated for differing aspects of cognition: alertness and wakefulness; concentration and focus; and learning and memory. We asked participants to rate whether they would ingest the drug, on a five-point scale; response categories were absolutely not, not likely, unsure, likely, or absolutely. If a participant responded with “unsure,” “not likely,” or “absolutely not” regarding ingestion of the drug, they were prompted to select from a list of reasons for avoidance. Participants were also given the option to enter their own reason for avoidance if the given list did not include it. A similar series of vignettes were utilized for another question, describing three new non-pharmacological, “natural supplement” cognitive enhancers. Participants were again asked to rate the likelihood that they would use the substance, as described above. Characteristics of the study participants were obtained from the frequency of responses. The statistical significance of the associations between predictors and outcome variables, as well as those between different outcome variables, was tested using Chi-square tests or Fisher’s exact tests. All analyses were performed using statistical software R V2.14.0 (http://cran.r-project.org/bin/windows/ base/old/2.14.0)
METHODS An anonymous, online survey consisting of eight multi-step questions (i.e., respondents were asked to fill in a chart similar to Table 2) concerning actual and hypothetical use of cognitive enhancers was sent out via e-mail to 647 medical students across all four years. A copy of the survey can be found at http://sgiz.mobi/s3/Cognitiveenhancement-in-Canadian-medical-students-a-nationalsurvey. Respondents attended a Canadian medical school (year 1 (n = 171); year 2 (n = 169); year 3 (n = 159); and year 4 (n = 148)). The data for the survey were collected between September and November 2011. Prior to wide release, the survey was piloted with a group of five medical students and an expert evaluator (see acknowledgements) and no ambiguities were identified. This study received approval from the university’s Research Ethics Board. The survey collected demographic data, including date of birth, gender, year of study, and highest level of parental education. Following this, the survey included a page of background information, where we stated the goal of the survey and provided the definition of a “cognitive enhancer” (i.e., the same definition used in the introduction). Participants were also asked to complete a chart containing a list of various cognitive enhancers they may have used (Table 2). Participants were asked not to fill in anything they took for purposes other than for cognitive enhancement, and to exclude anything taken on the advice of a prescribing professional. To assess attitudes towards the use of cognitive enhancers, we presented a series of vignettes describing the creation of three new pharmacological cognitive enhancers. Participants were told that each drug had proven efficacy,
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RESULTS Of the 647 medical students surveyed, 326 responded (50%). Male and female students were approximately equally distributed (51% M, 49% F), with no statistical differences between our sample and the class distribution (P = 0.54). Respondents included 192/340 (56%) junior students (from years 1 and 2), and 134/307 (44%) senior students (from years 3 and 4). There were no statistical differences between the distribution of our sample and the
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TABLE 3 Prevalence of recent use by attitudes towards hypothetical cognitive (alertness and wakefulness) enhancer use
Negative attitudes Neutral attitudes Positive attitudes
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∗ p-values
Coffee, tea, cola 98 p = 0.09 51 p = 0.44 118 p = 0.29
High-caffeine energy beverages 17 p < 0.01 10 p = 0.15 54 p < 0.01
Natural supplements 12 p < 0.01 12 p = 0.91 36 p < 0.01
Tobacco, decongestants 3 p = 0.74 2 p = 0.96 3 p = 0.94
Stimulant pharmaceuticals 1 p = 0.03 1 p = 0.46 12 p < 0.01
calculated based on chi-square statistics with one degree of freedom.
distribution of the actual class population, with regards to junior versus senior students (P = 0.066). As shown in Table 2, the lifetime prevalence of caffeine use (in the form of coffee, tea, or soda) was 92% (95% CI: 89% to 95%). One hundred and sixty-nine (52%, 95% CI: 47% to 57%) students admitted to the use of highcaffeine products, including high-caffeine energy drinks (e.g., “Red Bull”) and caffeine pills, for the purposes of enhancement. Male students were more likely to use highcaffeine products than female students (63% vs. 40%, P < 0.01), and senior medical students were more likely to use high-caffeine products than junior students (59% vs. 47%, P = 0.03). High-caffeine use was strongly associated with the use of stimulant substances (P < 0.01). Of the 49 (15%, 95% CI: 11% to 19%) students who admitted to off-label use of one or more pharmaceutical stimulants for cognitive enhancement (lifetime prevalence), 14 (4%, 95% CI: 2% to 6%) students had used stimulants within the last year (Table 2). The number of substances ingested by students, in order of reported lifetime prevalence, includes methylphenidate (Ritalin) (24 [7%]), modafinil (Provigil) (18 [6%]), dextroamphetamine (Dexedrine) (11 [3%]), dextro/levoamphetamine (Adderall) (10 [3%]), adrafanil (Olmifon) (5 [2%]), and piracetam (5 [2%]). Senior medical students were more likely than junior students to report use of stimulant substances within the past year (8% vs. 2%, P = 0.04). Attitudes and self-reported actions aligned. Male students (80 [53%]) were more likely than female students (49 [33%]) to have positive attitudes towards the use of a hypothetical cognitive enhancer indicated for alertness and wakefulness (p < 0.01). Compared with junior medical students (61 [35%]), senior medical students (67 [53%]) were also more likely to have positive attitudes towards the use of a hypothetical cognitive enhancer indicated for alertness and wakefulness (p < 0.01). No statistical differences in attitudes were found between agents indicated for alertness and wakefulness, concentration and focus, and learning and memory. Compared to medical students with negative and neutral attitudes towards cognitive enhancement, Journal of Psychoactive Drugs
those with favorable attitudes were more likely to use pharmaceutical stimulants (12 [86%], p < 0.01) and highcaffeine products (54 [66%], p < 0.01) within the last year (Table 3). We found no statistical differences between attitudes towards pharmacological or natural supplements. The most common reasons for avoidance were concerns regarding safety, dependency, and preservation of self-efficacy.
DISCUSSION This survey showed that 15% of medical students in the sampled Canadian institution reported non-medical and/or off-label use of pharmaceutical stimulants at some point in their life, and 52% admitted to use of high-caffeine products for the purposes of cognitive enhancement. A survey of American medical students found a prevalence of 10.1% for lifetime non-medical pharmaceutical stimulant use (methyphenidate or amphetamine salts) (Tuttle, Scheurich & Ranseen 2010). A similar study in a sample of American dental students found a 12.4% prevalence of pharmaceutical stimulant use (with the majority of use for cognitive-enhancement purposes) (McNiel et al. 2011). These results suggest that the use of cognitive enhancers in a healthcare student setting is higher than use among general student populations (6.9%) (McCabe et al. 2005). Increased use of cognitive enhancers in this population may be fuelled by increased levels of knowledge around the availability and utility of these substances. This, along with levels of stress (Dyrbye et al. 2006; Dyrbye, Thomas & Huntington 2006) and on-call hours, may help explain the association between year of medical study and recent use of pharmaceutical stimulants. Higher use and more positive attitudes among male students may reflect sex differences in risk-taking behavior. Non-medical pharmaceutical stimulant users, as well as those that use high-caffeine energy drinks (e.g., “Red Bull”), have been found to be more sensation-seeking, and exhibit traits of perfectionism (Low & Gendaszek 2002). 363
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They are significantly more likely to report use of alcohol, cigarettes, marijuana, ecstasy, cocaine, and engage in other risky behaviors (Arria, Caldeira & Kasperski 2010; Malinauskas, Aeby & Overton 2007; McCabe et al. 2005; Teter et al. 2005; Hughes & Olivetto 1997). This suggests that users of cognitive enhancers may be a high-risk population for substance abuse and/or mental health issues more generally. More research is necessary to determine whether the use of cognitive enhancers per se warrants intervention. These attitudes and behaviors have several implications. First, the personal use of cognitive enhancers, particularly pharmaceutical stimulants, in a clinical environment may have a direct impact on patient care, including a lower threshold for prescribing psycho-active medications (Banjo, Nadler & Reiner 2010). The use of cognitive enhancers may also be indicative of users’ failure to cope with academic or workplace demands, and be a marker for risk of later substance abuse—a particular concern given physicians’ ready access to psycho-active drugs, intrinsic job stresses, and the consequences of such substance abuse for patient safety. As it stands, up to 10% to 15% of all physicians will misuse drugs at some point during their career. It is estimated that 6% to 8% of physicians can be classified as having a substance use disorder, and the rates of use of certain drugs, including opiates and benzodiazepines, have been reported to be five times higher than rates in the general population (Balidisseri 2007). The implications of the self-reported use of high-dose caffeine substances are less clear, given the widespread consumption of caffeine worldwide. Nonetheless, studies have shown that both members of the general population and physicians are uncomfortable with the enhancement of cognition through pharmaceuticals (Bergstrom & Lynoe 2008; Malinauskas, Aeby & Overton 2007). In one such study, both general practitioners and the general public indicated that the use of natural remedies for cognitive enhancement was more acceptable than the use of pharmaceuticals (Bergstrom & Lynoe 2008). This finding aligns
with our survey results, wherein lifetime use of natural supplements for cognitive enhancement was twice as prevalent as that of pharmaceutical stimulants. Our survey also confirmed results from other studies that elucidated reasons for avoidance of cognitive enhancement (Bergstrom & Lynoe 2008); the most commonly cited reasons among those who denied use of cognitive enhancers were concerns regarding safety, dependency, and preservation of self-efficacy. A key limitation of this study is that it was carried out at a single institution; however, we have no reason to believe that the results are not generalizable to students studying elsewhere. While self-selection may have led to a positive response bias, it is equally plausible that non-respondents did not wish to disclose use of cognitive enhancers. It is possible that students misread the survey instructions and included substances taken on medical advice. Finally, the survey was sent out between September and November 2011, and these behaviors may fluctuate with stressors during the academic cycle.
CONCLUSION This study is the first to examine cognitive enhancement attitudes and behaviors in a sample of Canadian medical students. A surprising proportion of Canadian medical students in this sample engaged in non-medical and/or offlabel use of pharmaceutical stimulants and other substances for the purposes of cognitive enhancement. We do not know if these attitudes and behaviors are associated positively or negatively with clinical competency and, despite suggestive evidence from other populations, a relationship to later substance abuse remains hypothetical. Furthermore, students’ point of access to non-medical pharmaceutical stimulants remains unclear. All of these issues warrant further study, along with continuing attention to the academic and occupational stressors that might be leading to use of stimulants and so-called cognitive enhancers during medical training.
REFERENCES Czeisler, C.; Walsh, J.K.; Roth, T.; Hughes, R.J.; Wright, K.P.; Kingsbury, L.; Arora, S.; Schwartz, J.R.; Niebler, G.E. & Dinges, D.F. 2005. Modafinil for excessive sleepiness associated with shift-work sleep disorder. New England Journal of Medicine 353 (5): 476–86. Dyrbye, L.N.; Thomas, M.R. & Huntington, J.L. 2006. Personal life events and medical student burnout: A multicenter study. Academic Medicine 81: 374–84. Dyrbye, L.N.; Thomas, M.R. & Shanafelt, T.D. 2006. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic Medicine 81 (4): 354–73. Fisone, G.; Borgkvist, A. & Usiello, A. 2004. Caffeine as a psychomotor stimulant: Mechanism of action. Cell and Molecular Life Sciences 61 (7–8): 857–72. Greely, H.; Sahakian, B.; Harris, J.; Kessler, R.C.; Gazzaniga, M.; Campbell, P. & Farah, M.J. 2008. Towards responsible use of
Arria, A.M.; Caldeira, K.M. & Kasperski, S.J. 2010. Increased alcohol consumption, nonmedical prescription drug use, and illicit drug use are associated with energy drink consumption among college students. Journal of Addiction Medicine 4 (2): 74–80. Baldisseri, M.R. 2007. Impaired healthcare professional. Critical Care Medicine 35 (2 Suppl): S106–16. Banjo, O.C.; Nadler, R. & Reiner, P.B. 2010. Physician attitudes towards pharmacological cognitive enhancement: Safety concerns are paramount. PLoS One 5 (12): e14322. Bergström, L.S. & Lynöe, N. 2008. Enhancing concentration, mood and memory in healthy individuals: An empirical study of attitudes among general practitioners and the general population. Scandinavian Journal of Public Health 36 (5): 532–7. Chatterjee, A. 2004. Cosmetic neurology: The controversy over enhancing movement, mentation, and mood. Neurology 63 (6): 968–74. Journal of Psychoactive Drugs
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Downloaded by [Michigan State University] at 22:02 13 February 2015
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Minzenberg, M.J. & Carter, C.S. 2008. Modafinil: A review of neurochemical actions and effects on cognition. Neuropsychopharmacology : Official Publication of the American College of Neuropsychopharmacology 33 (7): 1477–502. Nehlig, A.; Daval, J.L. & Debry, G. 1992. Caffeine and the central nervous system: Mechanisms of action, biochemical, metabolic and psychostimulant effects. Brain Research. Brain Research Reviews 17 (2): 139–70. Repantis, D.; Schlattmann, P.; Laisney, O. & Heuser, I. 2010. Modafinil and methylphenidate for neuroenhancement in healthy individuals: A systematic review. Pharmacological Research : The Official Journal of the Italian Pharmacological Society 62 (3): 187–206. Reissig, C.J.; Strain, E.C. & Griffiths, R.R. 2009. Caffeinated energy drinks: A growing problem. Drug and Alcohol Dependence 99 (1–3): 1–10. Sahakian, B. & Morein-Zamir, S. 2007. Professor’s little helper. Nature 450 (7173): 1157–1159. Shapiro, R.E. 2008. Caffeine and headaches. Current Pain and Headache Reports 12 (4): 311–315. Teter, C.J.; McCabe, S.E.; Cranford, J.A.; Boyd, C.J. & Guthrie, S.K. 2005. Prevalence and motives for illicit use of prescription stimulants in an undergraduate student sample. The Journal of American College Health 53 (6): 253–62. Tuttle, J.P.; Scheurich, N.E. & Ranseen, J. 2010. Prevalence of ADHD diagnosis and nonmedical prescription stimulant use in medical students. Academic Psychiatry 34 (3): 220–3. Webb, J.R.; Thomas, J.W. & Valasek, M.A. 2010. Contemplating cognitive enhancement in medical students and residents. Perspectives in Biology and Medicine 53 (2): 200–14.
cognitive-enhancing drugs by the healthy. Nature 456 (7223): 702–5. Erratum in Nature 2008 Dec 18; 456 (7224): 872. Hughes, J.R. & Oliveto, A.H. 1997. A systematic survey of caffeine intake in Vermont. Experimental and Clinical Psychopharmacoly 5: 393–398. Killgore, W.D.; Rupp, T.L.; Grugle, N.L.; Reichardt, R.M.; Lipizzi, E.L. & Balkin, T.J. 2008. Effects of dextroamphetamine, caffeine and modafinil on psychomotor vigilance test performance after 44 h of continuous wakefulness. Journal of Sleep Research 17 (3): 309–321. Low, K.G. & Gendaszek, A.E. 2002. Illicit use of psychostimulants among college students: A preliminary study. Psychology, Health & Medicine 7 (3): 283–87. Lynch, G.; Palmer, L.C. & Gall, C.M. 2011. The likelihood of cognitive enhancement. Pharmacology, Biochemistry, and Behavior 99 (2): 116–29. Maher, B. 2008. Poll results: Look who’s doping. Nature 452 (7188): 674–5. Malinauskas, B.M.; Aeby, V.G. & Overton, R.F. 2007. A survey of energy drink consumption patterns among college students. Nutrition Journal 6: 35. McCabe, S.E.; Knight, J.R.; Teter, C.J. & Wechsler, H. 2005. Nonmedical use of prescription stimulants among US college students: Prevalence and correlates from a national survey. Addiction 100 (1): 96–106. Erratum in Addiction 2005 Apr; 100 (4): 573. McNiel, A.D.; Muzzin, K.B.; DeWald, J.P.; McCann, A.L.; Schneiderman, E.D.; Scofield, J. & Campbell, P.R. 2011.The nonmedical use of prescription stimulants among dental and dental hygiene students. Journal of Dental Education 75 (3): 365–76.
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