Use Among Young People
Guest: Dr. Robert Malcolm – Psychiatry & Behavioral
Host: Dr. Linda Austin – Psychiatry
Linda Austin: I’m Linda Austin. I’m interviewing Dr. Robert Malcolm who is
Professor of Psychiatry and an expert in several areas of psychiatry, among
them, sleep disorders as well as substance abuse. Dr. Malcolm, one of the things I’d love to
just pick your brain about is this very interesting issue of the widespread use
of stimulants among young people. As a
psychiatrist, you and I, both, have many young people, high school and college
aged kids come, they may have gotten a diagnosis of attention deficit disorder
(ADD) from another physician and want stimulants. I am often puzzled by this, not knowing if
they actually need the stimulants, if it’s just that they like the
stimulants. How do you, as a
psychiatrist begin to tease out the question of who should and who shouldn’t
Robert Malcolm: Dr. Austin, I really
think that’s a very interesting and common problem today. You know, I like to kind of wipe the slate
clean if I’m undecided. If they come to
me and they’re already on stimulants, I look at the context of their life. How well are they performing and, more
importantly, how well did they perform before they were put on stimulants? And I like some of these young people to take
a drug holiday. I like to see what
they’re like off of stimulants. Are they
eating well? Are they sleeping
well? And, what’s their performance like
at work or at school, off of medication?
one approach I take. And, you know, so
many times, and I bet you’ve had this experience too, we end up seeing people
who, although they say they meet the criteria for attention deficit disorder,
in point of fact, they may have an underlying problem with eating. They want to be slender and they want to use
a stimulant to control their eating, or they may have an underlying sleep
disorder and they’re trying to self-medicate for alertness. There are many, many reasons. So, I really like to start afresh and really
see what they’re like off of medication.
second thing I like to do is, often, refer them for neuropsychological testing,
if that’s feasible, to really get a sense of their cognitive functions in
depth. And, if, then, it looks to me
like they meet the criteria for attention deficit disorder, they were
functioning better on a stimulant and the neurocognitive testing, which is not
definitive, it’s not diagnostic, but it’s often very helpful, if all of those
things fall into place, then I’m going to put them back on the appropriate dose
of a stimulant. I’m going to stay within
FDA guidelines. I’m not going to
escalate dose, because if we’re escalating doses, that makes me wonder about
abuse or diversion. You know, you and I
have, both, seen students who sell their stimulants to other students for other
purposes. So, that’s sort of my view of
Linda Austin: I once had a conversation
with Dr. Judy Rappaport about this, who at the time was Head of the National
Institute of Mental health, and she made an interesting comment. She said, you know, the problem is, everybody
performs better with stimulants. She talked
about a study she’d done in which she’d actually used her own children as part
of the study, normal kids, no attention deficit disorder. They all performed better on stimulants just
as we all might do better in the morning after we’ve had a cup of coffee, or
two. And so, it becomes very hard to
know with some of these kids who say, my mind wanders when I study or I just
can’t kick in, I just can’t focus on my work unless I have my stimulant. Well, maybe they will do somewhat better on a
stimulant, but does that mean that they should all be getting stimulants?
Robert Malcolm: Absolutely not. And, of course, for many young people, the
answer is simply sleep deprivation.
They’re going to bed late at night.
They’re getting up early in the morning.
And, as you and I, both, know, adolescents, really, are what we call
delayed sleep phase individuals. They
like to go to bed late. They like to
sleep late. Most schools start early,
particularly in the south. So, a child
gets up in the morning, is expected to perform very early in the morning,
they’re sleepy, they can’t concentrate.
And before we know it, they’re labeled as having attention deficit
disorder, when, in fact, they’re sleep deprived.
have to look at all those factors. And
I’ve read Dr. Rappaport’s study. That’s
absolutely true. We all do better on stimulants,
but should we all be taking stimulants?
Absolutely not, because, for some of us, stimulants reduce our appetite
to the point where that’s dangerous, they reduce our sleep. They produce effects on our heart, such as
rises in blood pressure or irregularities of our heart. So, we have to put this in the right
context. Just because someone says they
have attention deficit disorder, certainly doesn’t mean they have it.
Linda Austin: You mentioned the upper
limits of stimulants. Let’s take amphetamine,
Adderall, what’s the upper limit that you would prescribe of Adderall?
Robert Malcolm: Usually about a
milligram per kilogram for a person. So,
if we have an average weight male, who’s 70 kg, 150 lbs., we’re talking about
70 mg per day, but only titrated up to that dose slowly and only if they really
need it, meaning that many people will respond to half that dose.
Linda Austin: How about adverse
psychological effects of stimulants, can you comment on that?
Robert Malcolm: Well, yes. You know, for some people who take
stimulants, they become very moody. They
become irritable. They become
aggressive. So, the detriments really
outweigh the pluses in those cases. And,
again, I think that’s part of the equation.
You know, are the benefits here, and are the risks such that they
outweigh the benefits? Even if the
person has attention deficit disorder, there are people I’ve seen and removed
from stimulants because they’ve had high blood pressure that required
medication treatment, or other consequences.
It’s very common to see one on stimulants that really requires taking
sleeping pills at night. That may not be
the best approach either.
Linda Austin: Dr. Malcolm, thank you so
Robert Malcolm: Thank you.
If you have any questions about the services
or programs offered at the Medical University of South
Carolina or if you would like to schedule an
appointment with one of our physicians, please call MUSC Health
Connection: (843) 792-1414.