Cartas aos Editores 393
Rev Bras Psiquiatr. 2009;31(4):387-95 References
1. Orford J. Disabling the public interest: gambling strategies and policies for Britain. Addiction. 2005;100(9):1219-25.
2. Wardle H, Sproston K, Orford J, Erens B, Griffiths M, Constantine R, Pigott S. British Gambling Prevalence Survey 2007. London: The UK Gambling Commission; 2007.
3. Hansen M, Rossow I. Adolescent gambling and problem gambling: does the total consumption model apply? J Gambl Stud.
2008;24(2):135-49.
4. Pechansky F, De Boni R, Diemen LV, Bumaguin D, Pinsky I, Zaleski M, Caetano R, Laranjeira R. Highly reported prevalence of drinking and driving in Brazil: data from the first representative household study. Rev Bras Psiquiatr. 2009;31(2):125-30.
5. Laranjeira R, Pinsky I, Zalesky M, Caetano R. I Levantamento Nacional sobre os padrões de consumo de álcool na população brasileira. Secretária Nacional Antidrogas - SENAD: Brasília, DF; 2007.
6. Robitaille E, Herjean P. An analysis of the accessibility of video lottery terminals: the case of Montréal. Int J Health Geogr. 2008;7:2. 7. Raylu N, Oei TP. Role of culture in gambling and problem gambling.
Clin Psychol Rev. 2004;23(8):1087-114.
Dear Editor,
Medical and psychiatric practices are shaped by the social and cultural environment in which they occur. Recent articles in scientific1 and lay2 publications about the use of drugs by healthy
people raised questions on the boundaries of our practice. We need to distinguish between those pharmacological interventions which primarily count as ‘therapies’ and those which count as ‘enhancements’. Therapies aim to treat, cure or prevent diseases; enhancements aim to improve normal skills. Drugs used to treat Attention Deficit/Hyperactivity Disorder (ADHD) may improve normal skills. That seems to be the case with stimulants such as methylphenidate. These drugs are also associated with diversion, abuse, dependence and sudden death.3 Although
discussions about legalization of stimulants use in healthy people at first seemed restricted to the USA, this use is probably occurring also in Brazil. However, rigorous systematic research is lacking. This is still a matter of anecdotal cases in private offices. Some details were changed to prevent patient identification.
Cognitive enhancers and Cosmetic
Psychiatry: are we ready? A
case-report
Cartas aos Editores 394
Rev Bras Psiquiatr. 2009;31(4):387-95 Case report: S. is a 21-year-old single woman who came to office
asking for help to get a job. She applied for a selection process and asked for a prescription of methylphenidate to improve her chances. She became aware of this drug through a friend that was studying with her and reported an important improvement in academic test performance. The friend was using pills from his sister. S. had already taken this medication once, noticing a discrete improvement in her capabilities. There was no current or lifetime diagnosis of ADHD or any other psychiatric disorders. The performance in ASRS4 test was
within the normal range. The risks and benefits of using stimulants in this manner were explained to her. General orientation about study, sleep, diet, leisure and relationships with others were highlighted. Methylphenidate was not prescribed. The patient seemed dissatisfied at the end of the appointment. A new appointment was scheduled, but the patient did not show up.
Discussion: Changing cultural values may put pressures on clinicians’ decisions in order to prescribe performance enhancing drugs. We may be facing a paradigm shift towards Cosmetic
References
1. Greely H, Sahakian B, Harris J, Kessler RC, Gazzaniga M, Campbell P, Farah MJ. Towards responsible use of cognitive-enhancing drugs by the healthy. Nature. 2008;456(7223):702-5. Erratum in: Nature. 2008;456(7224):872.
2. Smart drugs: Drugs to make you cleverer are in the test-tube. Good Economist. 2008;24 May:22.
3. Gould MS, Walsh BT, Munfakh JL, Kleinman M, Duan N, Olfson M, Greenhill L, Cooper T. Sudden death and use of stimulant medications in youths. Am J Psychiatry. 2009;166(9):992-1001.
4. Mattos P, Segenreich D, Saboya E, Louzã M, Dias G, Romano M. Transcultural adaptation of the adult self-report scale into Portuguese for evaluation of adult attention-deficit/hyperactivity disorder (ADHD). Rev Psiquiatr Clin. 2006;(33):188-94.
5. Chatterjee A. The promise and predicament of cosmetic neurology. J Med Ethics. 2006;32(2):110-3.
Psychiatry. To go beyond therapy seems inevitable.5 Dermatology
and plastic surgery have already changed. Society has evolved to accept the risks if the benefits are culturally valued. However, there are serious concerns; we don’t know the risks of long term treatments both in patients and in healthy people.
The treatment of ADHD for all ages in the public health system in Brazil is far from ideal. Most patients do not receive any support. There has been an increased interest in using these drugs as enhancers in some social strata. We need to identify and define ethical issues raised by recent discussions and social pressures in order to anticipate and respond to clinical changes and public concerns. This may lead, where necessary, to the formulation of new guidelines or rules by the appropriate regulatory agencies.
Marcelo Victor
ADHD Outpatient Program – Adult Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre (RS), Brazil
The impact of marital status in
hospitalized patients with bipolar
disorder
O impacto da situação conjugal em
paci-entes internados com transtorno do humor
bipolar
Dear Editor,
Many studies show that bipolar disorder (BD) causes ever-increasing distress to caregivers, which leaves many with a feeling of being overburdened. When caregivers believe that they are capable of controlling the patient’s disease this feeling is reduced. This belief has been associated with good coping strategies, or coping style, which can in turn reduce rates of hospitalization.1
In a recent study with BD patients, the authors demonstrated that when patients were substance abusers, and were also separated from their partner, they had a 100% risk of hospitalization. The presence of a partner reduced this risk on 52%, and the lowest risk of hospitalization was associated with the presence of a partner and absence of drug involvement.2 It is also known that almost
