Use of neuroenhancement drugs: prevalence, frequency and use expectations in Switzerland

Substance use and its association with mental health among Swiss medical students: A cross-sectional study

BACKGROUND

Studies on mental health and substance use among medical students indicated worrying prevalence but have been mainly descriptive.

AIM

To evaluate the prevalence of substance use in a sample of medical students and investigate whether mental health variables have an influence on substance use.

METHODS

The data were collected as part of the first wave of the ETMED-L, an ongoing longitudinal open cohort study surveying medical students at the University of Lausanne (Switzerland). N = 886 students were included and completed an online survey including measures of mental health (depression, suicidal ideation, anxiety, stress, and burnout) and use of and risk related with several substances (tobacco, alcohol, cannabis, cocaine, stimulants, sedatives, hallucinogens, opioids, nonmedical prescription drugs, and neuroenhancement drugs). We evaluated the prevalence of use of each substance and then tested the association between mental health and substance use in an Exploratory Structural Equation Modeling framework.

RESULTS

Statistical indices indicated a four-factor solution for mental health and a three-factor solution for substance use. A factor comprising risk level for alcohol, tobacco, and cannabis use - which were the most prevalent substances - was significantly associated with a burnout factor and a factor related to financial situation and side job stress. There was a significant association between a factor comprising depression, anxiety, and suicidal ideation and a factor related to the use of sedatives, nonmedical prescription drugs and neuroenhancement drugs. Although their use was less prevalent, a factor comprising the risk level of stimulants and cocaine use was significantly but more mildly related to the burnout factor. A factor comprising stress related to studies and work/life balance as well as emotional exhaustion was not related to substance use factors.

CONCLUSION

In this sample of medical students, the prevalence of substance use was substantial and poorer mental health status was related with higher substance use risk levels.

The relevance of pharmacological neuroenhancement for stress and resilience-A multistudy report

Background

Pharmacological neuroenhancement (PNE) is discussed as coping strategy in academic and work-related contexts. Depending on the definition of PNE and sample population, different prevalence rates for various groups have been reported. In the three parts of the study, prevalence rates for work and student populations in Germany are detected and the reasons for PNE and possible causal associations between PNE, stress and resilience are investigated.

Methods

In part 1 of the study, 152 occupational physicians (OPs) were surveyed about prevalence rates and reasons for PNE. In part 2 of the study, 1,077 German students reported on their PNE behavior. 704 students were then longitudinally considered to draw conclusions on causal associations between PNE, stress, and resilience.

Results

The OPs' estimated prevalence rate of 10.9% in a working population is higher than the prevalence rate of 5.4% for prescription and illicit substances found in the student sample in part 2 of the study. The reason suspected by OPs to be most important for PNE with prescription drugs were performance pressure and long working hours. Using soft enhancers, such as caffeine, is most common with a prevalence rate of 76.8% in the student sample. Stress predicts a higher (β = 0.179, p < 0.001) and resilience a lower use of PNE (β = -0.13, p = 0.001). Resilience predicts a lower (β = -0.35, p < 0.001) and PNE a higher level of stress (β = 0.11, p < 0.001).

Conclusion

OPs suspect a prevalence rate of 10.9% among the working population, while we found a prevalence rate of 5.4% among students. Caffeine is the most used substance for PNE, while the use of prescription and illicit substances remains low. Higher levels of stress and lower levels of resilience result in a higher use of PNE. Universities should therefore include the promotion of resilience and methods for dealing with study stress in health programs to reduce PNE.

Study protocol for the ETMED-L project: longitudinal study of mental health and interpersonal competence of medical students in a Swiss university using a comprehensive framework of empathy

INTRODUCTION

Physician interpersonal competence is crucial for patient care. How interpersonal competence develops during undergraduate medical education is thus a key issue. Literature on the topic consists predominantly of studies on empathy showing a trend of decline over the course of medical school. However, most existing studies have focused on narrow measures of empathy. The first aim of this project is to study medical students' interpersonal competence with a comprehensive framework of empathy that includes self-reported cognitive and affective empathy, performance-based assessments of emotion recognition accuracy, and a behavioural dimension of empathy. The second aim of the present project is to investigate the evolution of mental health during medical school and its putative link to the studied components of interpersonal competence. Indeed, studies documented a high prevalence of mental health issues among medical students that could potentially impact their interpersonal competence. Finally, this project will enable to test the impact of mental health and interpersonal competence on clinical skills as evaluated by experts and simulated patients.

METHODS AND ANALYSIS

This project consists of an observational longitudinal study with an open cohort design. Each year during the four consecutive years of the project, every medical student (curriculum years 1-6) of the University of Lausanne in Switzerland will be asked to complete an online questionnaire including several interpersonal competence and mental health measures. Clinical skills assessments from examinations and training courses with simulated patients will also be included. Linear mixed models will be used to explore the longitudinal evolutions of the studied components of interpersonal competence and mental health as well as their reciprocal relationship and their link to clinical skills.

ETHICS AND DISSEMINATION

The project has received ethical approval from the competent authorities. Findings will be disseminated through internal, regional, national and international conferences, news and peer-reviewed journals.

The Use and Impact of Cognitive Enhancers among University Students: A Systematic Review

INTRODUCTION

Cognitive enhancers (CEs), also known as "smart drugs", "study aids" or "nootropics" are a cause of concern. Recent research studies investigated the use of CEs being taken as study aids by university students. This manuscript provides an overview of popular CEs, focusing on a range of drugs/substances (e.g., prescription CEs including amphetamine salt mixtures, methylphenidate, modafinil and piracetam; and non-prescription CEs including caffeine, cobalamin (vitamin B12), guarana, pyridoxine (vitamin B6) and vinpocetine) that have emerged as being misused. The diverted non-prescription use of these molecules and the related potential for dependence and/or addiction is being reported. It has been demonstrated that healthy students (i.e., those without any diagnosed mental disorders) are increasingly using drugs such as methylphenidate, a mixture of dextroamphetamine/amphetamine, and modafinil, for the purpose of increasing their alertness, concentration or memory.

AIM

To investigate the level of knowledge, perception and impact of the use of a range of CEs within Higher Education Institutions.

METHODOLOGY

A systematic review was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Whilst 1400 studies were identified within this study through a variety of electronic databases (e.g., 520 through PubMed, 490 through Science Direct and 390 through Scopus), 48 papers were deemed relevant and were included in this review.

RESULTS

The most popular molecules identified here included the stimulant CEs, e.g., methylphenidate, modafinil, amphetamine salt mixtures and caffeine-related compounds; stimulant CEs' intake was more prevalent among males than females; drugs were largely obtained from friends and family, as well as via the Internet. It is therefore suggested that CEs are increasingly being used among healthy individuals, mainly students without any diagnosed cognitive disorders, to increase their alertness, concentration, or memory, in the belief that these CEs will improve their performance during examinations or when studying. The impact of stimulant CEs may include tolerance, dependence and/or somatic (e.g., cardiovascular; neurological) complications.

DISCUSSION

The availability of CEs for non-medical indications in different countries is influenced by a range of factors including legal, social and ethical factors. Considering the risk factors and motivations that encourage university students to use CE drugs, it is essential to raise awareness about CE-related harms, counteract myths regarding "safe" CE use and address cognitive enhancement in an early stage during education as a preventative public health measure.

Prescription Stimulant Misuse and ADHD Symptomatology Among College Students in Iceland

Objective: Misuse of prescription stimulant medication is a prevalent problem on American college campuses; however, few studies have been conducted beyond the United States. Although Iceland has the highest methylphenidate prescription rates in the world, prevalence of stimulant misuse within the Icelandic college student population remains to be investigated. Method: We examined the prevalence of prescription stimulant misuse among N = 521 college students in Iceland, using an online survey. Results: Overall prevalence of lifetime stimulant misuse was approximately 13%; 11% among participants without a prescription for stimulant medication, and 42% among participants holding a prescription. The primary reported reason for misuse was academic enhancement; risk factors included male sex, anxiety symptoms, and ADHD symptomatology. Conclusion: The present findings have implications for public health policy in Iceland, particularly as it relates to the college population. Prevention and intervention programs that provide college students with safer strategies to manage academic demands are warranted.

Pharmacological cognitive enhancement in pediatrics

PURPOSE OF REVIEW

Given the pervasiveness of psychotropic medication in the youth population and an increasingly competitive culture regarding educational performance, children, teenagers, and/or their parents may increasingly seek psychotropic substances in an effort to enhance a student's cognitive abilities and/or academic performance. Physicians must become aware of this very important and clinically relevant issue and work to ensure that medications remain in the hands of patients seeking wellness and not enhancement.

RECENT FINDINGS

The current article highlights findings on the pervasiveness of stimulant misuse and diversion in youth, the motivations and effects of stimulant use, health and legal consequences associated with use, and physician perceptions and preventive practices. Ethical concerns regarding pharmacological cognitive enhancement in pediatrics are also outlined - including coercion for nonusers, inequities in access, and threats to an individual's sense of self with regard to authenticity and autonomy.

SUMMARY

Pharmacological cognitive enhancement in pediatrics will become a larger, clinically relevant issue in the coming years. Physicians who care for children and adolescents must become more aware of this issue. Given the myriad health, legal, and ethical concerns, clinicians should discourage use of pharmaceuticals for enhancement purposes in the pediatric population.

Mining Patients' Narratives in Social Media for Pharmacovigilance: Adverse Effects and Misuse of Methylphenidate

Background: The Food and Drug Administration (FDA) in the United States and the European Medicines Agency (EMA) have recognized social media as a new data source to strengthen their activities regarding drug safety.

Objective: Our objective in the ADR-PRISM project was to provide text mining and visualization tools to explore a corpus of posts extracted from social media. We evaluated this approach on a corpus of 21 million posts from five patient forums, and conducted a qualitative analysis of the data available on methylphenidate in this corpus.

Methods: We applied text mining methods based on named entity recognition and relation extraction in the corpus, followed by signal detection using proportional reporting ratio (PRR). We also used topic modeling based on the Correlated Topic Model to obtain the list of the matics in the corpus and classify the messages based on their topics.

Results: We automatically identified 3443 posts about methylphenidate published between 2007 and 2016, among which 61 adverse drug reactions (ADR) were automatically detected. Two pharmacovigilance experts evaluated manually the quality of automatic identification, and a f-measure of 0.57 was reached. Patient's reports were mainly neuro-psychiatric effects. Applying PRR, 67% of the ADRs were signals, including most of the neuro-psychiatric symptoms but also palpitations. Topic modeling showed that the most represented topics were related to Childhood and Treatment initiation, but also Side effects. Cases of misuse were also identified in this corpus, including recreational use and abuse.

Conclusion: Named entity recognition combined with signal detection and topic modeling have demonstrated their complementarity in mining social media data. An in-depth analysis focused on methylphenidate showed that this approach was able to detect potential signals and to provide better understanding of patients' behaviors regarding drugs, including misuse.

L-carnitine for cognitive enhancement in people without cognitive impairment

BACKGROUND

Safe interventions to enhance cognitive function in cognitively healthy people would be very valuable for several reasons, including a better quality of life and professional success. While L-carnitine has been reported to enhance cognitive function in some conditions, its efficacy is disputed. The evidence of its efficacy for cognitively healthy people has not previously been systematically reviewed.

OBJECTIVES

To assess the efficacy and safety of L-carnitine for the enhancement of cognitive function in people without cognitive impairment.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialized Register, on 4 November 2016. We used the search terms 'L-carnitine' or 'acetyl-L-carnitine' or 'propionyl-L-carnitine' or 'ALC' or 'PLC' or 'ALCAR' or 'ALPAR'. We ran additional separate searches in several other sources to ensure that we retrieved the most up-to-date results. We also reviewed the bibliographies of the randomised controlled trials identified and contacted the authors and known experts in the field and pharmaceutical companies to identify additional published or unpublished data.

SELECTION CRITERIA

Eligible trials were randomised controlled trials (RCTs) or quasi-RCTs, parallel-group or cross-over, that compared L-carnitine or its derivatives, acetyl-L-carnitine or propionyl-L-carnitine, at any dose and for any length of treatment, with placebo or no treatment in cognitively healthy people of any age and either gender.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently selected trials and evaluated the methodological quality, then extracted and analysed data from the included trials.

MAIN RESULTS

Only two RCTs were eligible. One was a cross-over trial with 18 participants. The other randomised 400 participants to one of four treatments, of which two (L-carnitine and placebo) were relevant to this review, but the exact numbers of participants in these two treatment groups was not reported. All participants were young adults. Methodological details were poorly reported, and we considered the risk of bias in both studies to be unclear. The trials assessed different cognitive outcomes. We could extract cognitive data on approximately 200 participants from one trial. We found no evidence that L-carnitine has any effect on reaction time, vigilance, immediate memory, or delayed recall after three days of treatment. This trial report stated that there was a small number of adverse effects, none of which were serious. The small cross-over trial also reported no effect of L-carnitine on cognition, but did not provide data; no information was provided on adverse effects. We considered the available evidence to be of very low quality for all reported outcomes.

AUTHORS' CONCLUSIONS

Due to the limited number of included trials, short-term treatment, and inadequate reporting, we were unable to draw any conclusions about the efficacy or safety of L-carnitine for cognitive enhancement in healthy adults. Well-designed, randomised, placebo-controlled trials of L-carnitine for cognition enhancement in cognitively healthy people, with large samples and relatively long-term follow-up, are still needed.

Prescription stimulant medication misuse: Where are we and where do we go from here?

Prescription stimulants, including methylphenidate (e.g., Ritalin) and amphetamine compounds (e.g., dextroamphetamine; Adderall), have been approved by the U.S. Food and Drug Administration for the treatment of attention-deficit/hyperactivity disorder (ADHD) and are classified by the United States Drug Enforcement Administration as Schedule II medications because of their high potential for abuse and dependence (Drug Enforcement Administration, U.S. Department of Justice, 2015). Despite the potential health and judicial consequences, misuse of prescription stimulants, typically defined as taking stimulants without a valid prescription, or use of stimulants other than as prescribed, has become a serious problem in the United States and abroad, especially on college campuses. The purpose of the present article is to review historical information concerning prescription stimulants and to summarize the literature with respect to misuse among adults, particularly college students, including risk factors, mediators and moderators, and motivations for prescription stimulant misuse. In addition, evidence is presented concerning the question of whether prescription stimulants truly enhance cognitive functioning in individuals with and without ADHD, and the ethical and professional implications of these findings are explored. Lastly, recommendations for addressing prescription stimulant misuse and suggestions for future research are advanced. (PsycINFO Database Record

Prevalence of and motives for pharmacological neuroenhancement in Switzerland--results from a national Internet panel

AIMS

To estimate the prevalence of self-reported pharmacological neuroenhancement (PNE) with prescription or recreational drugs among the Swiss general population and correlates of PNE.

DESIGN

A population-based cross-sectional study using a self-administered online survey.

SETTING

A telephone-recruited highly representative internet panel in Switzerland.

PARTICIPANTS

A total of 10,171 Swiss employees and students (unweighted n = 10,084) aged 15-74 years (mean age: 39.1 ± 13.3; 46.6% female).

MEASUREMENTS

Self-reported life-time, past-year and past-month use of prescription or recreational drugs for PNE, motives for use and correlates of PNE, including socio-demographic, health and recreational drug use characteristics.

FINDINGS

The life-time prevalence of PNE was 4.0% [95% confidence interval (CI) = 3.62, 4.38], and the past-year prevalence was 2.1% (95% CI = 1.82, 2.38). Life-time pharmacological mood enhancement (3.1%; 95% CI = 2.76, 3.44) was more prevalent than pharmacological cognitive enhancement (1.4%; 95% CI = 1.17, 1.63). Fifty-four participants reported both (0.5%; 95% CI = 0.36, 0.64). PNE was associated with studying rather than full-time [odds ratio (OR) = 0.35; 95% CI = 0.21, 0.57] or part-time employment (OR = 0.39; 95% CI = 0.23, 0.67), stress (OR = 1.51 95% CI = 1.31, 1.75), cocaine (OR = 2.40; 95% CI = 1.51, 3.82) and amphetamine use (OR = 2.44; CI 95% = 1.37, 4.33), diagnosis of a mental disorder (OR = 4.26; 95% CI = 3.14, 5.80), and perceived poor health (OR = 0.76; 95% CI = 0.64, 0.90).

CONCLUSIONS

Taking prescription or recreational drugs for pharmacological neuroenhancement is rare among Swiss employees and students (4.0%). Pharmacological mood enhancement (3.1%) is more prevalent than direct pharmacological cognitive enhancement (1.4%).

The Swiss Cohort Study on Substance Use Risk Factors – Findings of two Waves

Abstract. Aim: To summarize published findings in peer-reviewed journals of the first two waves of the Swiss Cohort Study on Substance Use Risk Factors (C-SURF), a longitudinal study assessing risk and protective factors of 5,987 young men during the phase of emerging adulthood (20 years at baseline, followed-up 15 months later). Methods: Included were 33 studies published until November 2014 focusing on substance use. Results: Substance use in early adulthood is a prevalent and stable behavior. The 12-month prevalence of nonmedical use of prescription drugs (10.6 %) lies between that of cannabis (36.4 %) and other illicit drugs such as ecstasy (3.7 %) and cocaine (3.2 %). Although peer pressure in the form of misconduct is associated with increased substance use, other aspects such as peer involvement in social activities may have beneficial effects. Regular sport activities are associated with reduced substance use, with the exception of alcohol use. Young men are susceptible to structural conditions such as the price of alcohol beverages or the density of on-premise alcohol outlets. Particularly alcohol use in public settings such as bars, discos or in parks (compared with private settings such as the home) is associated with alcohol-related harm, including injuries or violence. Being a single parent versus nuclear family has no effect on alcohol use, but active parenting does. Besides parenting, religiousness is an important protective factor for both legal and illegal substance use. Merely informing young men about the risks of substance use may not be an effective preventive measure. At-risk users of licit and illicit substances are more health literate, e. g., for example, they seek out more information on the internet than non-at-risk-users or abstainers. Discussion: There are a number of risk and protective substance use factors, but their associations with substance use do not necessarily agree with those found outside Europe. In the United States, for example, heavy alcohol use in this age group commonly takes place in private settings, whereas in Switzerland it more often takes place in public settings. Other behaviors, such as the nonmedical use of prescription drugs, appear to be similar to those found overseas, which may show the need for targeted preventive actions. C-SURF findings point to the necessity of establishing European studies to identify factors for designing specific preventive actions.

The Use of Prescription Drugs and Drugs of Abuse for Neuroenhancement in Europe

Abstract. Pharmacological neuroenhancement, defined as the misuse of prescription drugs, illicit drugs, or alcohol for the purpose of enhancing cognition, mood, or prosocial behavior, is not widespread in Europe – nevertheless, it does occur. Thus far, no drug has been proven as safe and effective for cognitive enhancement in otherwise healthy individuals. European studies have investigated the misuse of prescription and illicit stimulants to increase cognitive performance as well as the use of tranquilizers, alcohol, and cannabis to cope with stress related to work or education. Young people in educational settings report pharmacological neuroenhancement more frequently than those in other settings. Although the regular use of drugs for neuroenhancement is not common in Europe, the irregular and low-dose usage of neuroenhancers might cause adverse reactions. Previous studies have revealed that obtaining adequate amounts of sleep and using successful learning techniques effectively improve mental performance, whereas pharmacological neuroenhancement is associated with ambiguous effects. Therefore, non-substance-related alternatives should be promoted to cope with stressful situations. This paper reviews the recent research on pharmacological neuroenhancement in Europe, develops a clear definition of the substances used, and formulates recommendations for practitioners regarding how to react to requests for neuroenhancement drug prescriptions. We conclude that monitoring the future development of pharmacological neuroenhancement in Europe is important to provide effective preventive measures when required. Furthermore, substance use to cope with stress related to work or education should be studied in depth because it is likely more prevalent and dangerous than direct neuroenhancement.