Stimulants: Use Among Young People

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Stimulants: Use Among Young People




Guest:  Dr. Robert Malcolm – Psychiatry & Behavioral Sciences

Host:  Dr. Linda Austin – Psychiatry


Dr. 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 get stimulants?


Dr. 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? 


That’s 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.


The 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 this. 


Dr. 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?


Dr. 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.


So, we 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.


Dr. 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?


Dr. 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.


Dr. Linda Austin:  How about adverse psychological effects of stimulants, can you comment on that?


Dr. 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.


Dr. Linda Austin:  Dr. Malcolm, thank you so much.


Dr. Robert Malcolm:  Thank you.


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