Pharmacological cognitive enhancers (PCEs) are licensed to improve cognitive functioning in those suffering from specific medical disorders like dementia, attention deficit hyperactivity disorder (ADHD) and daytime sleepiness associated with narcolepsy, with Nicholson et al (2015) observing that ‘healthy individuals use PCEs without a prescription for non-medical purposes … [and is] ‘largely restricted to students, with very little evidence for use in working populations.’
In the largest study on PCEs conducted, Maier et al (2018) reported on data collected from over 100 000 participants in 15 countries as part of the Global Drug Survey 2015 and 2017. They found that 4.9% and 13.7% of the global samples, respectively, reported the 12-month use of prescription or illegal stimulants and/or modafinil to improve work or study performance, an average increase of 180%. Expanding on this, while Mann (2021) ascribes this trend to be associated with students in higher education, he acknowledges that accurate prevalence rates are imprecise amonst stuents, ranging from 5% to 35% of student populations. However, Sharif et al (2021) cite evidence that the lifetime prevalence rate of prescribed PCEs intake for non-medical reasons, ‘as a self-attempt to increase cognitive performances, among university students in the UK and Ireland has been estimated to be around 10%.’
The most popular PCEs are dextroamphetamine salts (brand names: Adderall, Mydayis) and methylphenidate (brand name: Ritalin), used in the treatment of ADHD, and modafinil (brand names like Provigil) used as a treatment for narcolepsy (Mann, 2021).
Might PCEs – by increasing the possibility of a student achieving higher marks than they might otherwise have done – represent neuroscientific progress? Perhaps. But there is an ethical dimension that demands exploration. At a general level, political scientist Francis Fukuyama points out that ‘The original purpose of medicine is to heal the sick, not turn healthy people into gods’ (Fukuyama, 2002), while Mann (2021) considers whether students using PCEs are cheating or merely expressing a spirit of ‘competitive entrepreneurialism’. More specifically, Zaami et al (2020) highlight the neurological and psychiatric consequences of misusing methylphenidate analogues; these include impulsive behaviour, verbal, visual and memory impairment, gambling, compulsive shopping, and hypersexuality. Further, so-called psychostimulants can alter the glutamatergic system, ‘which can result in the impairment of behavioural flexibility and lead to the development and/or potentiation of addictive behaviours’, and Zaami et al (2020) note that the Australian Alcohol and Drug Foundation doubt the cognitive benefits conferred by most PCEs and suggest that there are few benefits for cognitive enhancement in healthy individuals, with associated side effects posing health risks.
Koren and Korn (2021) are clear that as far as methylphenidate is concerned, millions of healthy young people taking a restricted drug ‘with no response by the medical community should not be acceptable and must lead us to a change’ and they propose that an ethical-clinical debate on the topic should be followed by an action plan.
Meanwhile, what non-pharmacological interventions are freely available? Nicholson et al (2015) cite physical exercise as a well-established cognition enhancer and note a growing interest in factors like diet. And when Brunner et al (2017) examined whether six 60-minute sessions of yoga training – including mindfulness meditation practice – could improve working memory, they found that completion of this programme was associated with significant improvements in measures of working memory. However, the nature of the relationship between physical exercise and cognitive enhancement is not quite clear cut. For example, when Batmyagmar et al (2019) investigated whether long-term high-intensity endurance training affected cognitive and physical performance in healthy older people, they found no strong evidence that such training reduced cognitive impairment in later age, although elderly athletes reported a significantly better quality of life. Batmyagmar et al (2019) suggest that prolonged endurance training requires time and minimises social contact, which is an important aspect of healthy cognitive function. Another possible explanation is that high concentrations of free radicals are produced during high-intensity endurance training, ‘which at a senior age might not be as effectively counteracted due to reduced anti-oxidative capacity, thereby leading to damage to the central nervous system’ (Batmyagmar et al, 2019).
On balance, it appears that PCEs should only be used when clinically indicated rather than as a questionable means of passing exams.