Lifestyle drugs, mood, behaviour and cognition

Editorial
Éditorial
Lifestyle drugs, mood, behaviour and cognition
Simon N. Young, PhD
Co-editor-in-chief, Journal of Psychiatry & Neuroscience, and Department of Psychiatry, McGill University, Montréal, Que.
According to a recent article in Nature Medicine,1 the rounding lifestyle drugs and discussed 2 definitions of market for lifestyle drugs is forecast to rise from its cur- lifestyle drugs offered in a recent report.3 The first is rent $20 billion to over $29 billion by 2007. As a result of any drug intended or used for a condition that falls this booming market, companies have invested over into the border zone between medical and social defin- $20 billion in research on such drugs since the 1990s. Ob- itions of health. The second is any drug intended to viously, lifestyle drugs have important financial implica- treat a disease that results from a person's lifestyle tions, but what exactly is a "lifestyle drug"? The above- choices. The second definition certainly does not fit mentioned article defines lifestyle drugs as medicines with the way the term is typically used - baldness and that treat conditions associated with lifestyle; examples social anxiety disorder are not the result of lifestyle include drugs to treat weight loss, smoking, impotence, choices. The first definition is better, but not entirely baldness and the effects of aging, as well as medications satisfactory. Attempts to treat baldness and enhance that improve mental agility. This definition is not satis- mental agility are not matters of health, but preference.
factory, however. An antipsychotic medication will cer- Two factors seem to be important when the term tainly improve the lifestyle of a patient with schizophre- "lifestyle drug" is used. The person taking the drug per- nia and therefore fits the definition, but the term lifestyle ceives that it will increase her or his happiness, and the drug obviously has a somewhat different meaning.
person using the term, or a significant portion of society, The controversy about lifestyle drugs was stimulated does not consider the target symptom or symptoms to mainly by the use of fluoxetine (Prozac) and sildenafil be a "real" disease or disorder. This raises the issue of (Viagra). In the case of fluoxetine, the issue was its use what is and is not considered a disease. In a survey re- in people who did not fulfill the criteria for a psychiatric ported in the British Medical Journal in 1979,4 various disorder. However, although paroxetine (Paxil), an- groups were asked whether they considered certain con- other selective serotonin reuptake inhibitor (SSRI), is ditions to be diseases. The percentages of medical acade- not usually considered a lifestyle drug when it is used mics who did not consider schizophrenia, alcoholism to treat depression, the popular press has certainly writ- and depression to be diseases were about 20%, 40% and ten about it as a lifestyle drug when it is used to treat 50%, respectively. However, attitudes have probably social anxiety disorder. Obviously, social anxiety dis- changed over the past 2 decades, particularly in relation order is not considered to be on par with disorders such to depression. More recently, the British Medical Journal as depression or schizophrenia. This is despite the fact ran a vote on bmj.com to identify the "top 10 non-dis- that social anxiety disorder is clearly defined, is closely eases."5 The top 6 were aging, work, boredom, bags related to other anxiety disorders and can cause consid- under the eyes, ignorance and baldness. Unhappiness came in at number 14 and loneliness at 20. Although Lexchin2 addressed some of the controversies sur- most would agree that unhappiness and loneliness are Correspondence to: Dr. Simon N. Young, Department of Psychiatry, McGill University, 1033 Pine Ave. W, Montréal QC H3A 1A1; fax
514 398-4370; simon.young@mcgill.ca
Medical subject headings: disease; drug industry; drug therapy; emotions; legislation, drug; mood disorders; self medication.
J Psychiatry Neurosci 2003;28(2):87-9.
J Psychiatry Neurosci 2003;28(2)
not diseases, they are feelings that most people would is often appropriate, the debate moves on to the degree prefer not to have and can predispose to diseases. But to of unhappiness for which a pharmacological interven- what extent should unhappiness, as opposed to clinical tion is appropriate. The next step is to consider if or depression, be something that is treated with a drug? when it is appropriate to use chemicals to change a Attempts to increase happiness through pharmacol- neutral mood to happiness or increase the degree of ogy go back to our earliest history with the use of alco- happiness. A similar debate has already started in the hol, the cannabinoids and other naturally occurring area of memory and cognition. A recent review in compounds. The extensive use of drugs of abuse is, in Nature Reviews Neuroscience8 entitled "Smart Drugs: Do part, a short-sighted attempt to increase happiness. The they work? Are they ethical? Will they be legal?" lists 9 future will see increasing demand for drugs that in- classes of drugs that are currently under investigation crease happiness and do not have the adverse effects of as cognitive enhancers and discusses some of the issues the older drugs. The debate about the use of fluoxetine related to the use of such drugs by people whose cogni- in people without a DSM disorder will pale in compari- tive abilities are in the normal range.
son with the debates that will ensue with the discovery The development of drugs that healthy people may of drugs that raise mood in mentally healthy people, take to enhance their mental state creates considerable with limited or no side effects. Will such drugs really be problems for regulatory agencies. Even for one of the discovered? The idea that a single compound could original lifestyle drugs, alcohol, there is little agreement raise mood; decrease blood pressure, cortisol and sub- on how it should be regulated. Some countries use total jective responses to acute psychological stress; and in- prohibition, and others place limits on where it can be crease the frequency of sexual intercourse in healthy sold, the age of those who can buy it and when and young adults (particularly in women) without any im- where it can be drunk or increase taxation to decrease portant side effects is one that invites skepticism. How- the amount sold. In some situations, regulations owe ever, if results in recent issues of Psychopharmacology6 more to tradition than to rational consideration of risk and Biological Psychiatry7 are to be believed, such a and benefit. Current governmental regulations permit a compound already exists. It is high-dose (3 g/d) ascor- 9-year-old who is about to take an exam to buy and in- bic acid. There is also accumulating evidence that the gest a mixture of 2 compounds, both of which may en- omega-3 fatty acids in fish oils have beneficial effects on hance exam performance. The mixture comes in the mood and behaviour that may not be limited to the form of a cola, and the 2 compounds are caffeine and treatment of psychopathology. If ascorbic acid and fish glucose. Caffeine can enhance arousal and attention, but oils can have these effects, surely other more effective can also enhance anxiety and, in excess, can cause in- but still nontoxic compounds will be discovered.
somnia and a variety of other symptoms. Caffeine de- The debate about lifestyle drugs that influence the pendence can occur, although withdrawal symptoms brain is caused in part by the continuum in some areas are relatively mild. If caffeine was not used traditionally between normal and abnormal functioning. This is an and it was proposed as a cognitive enhancer today, the issue that psychiatry has grappled with for a long time chances of it being approved for use in children would - for example, in debates about the boundaries of an be small. The memory-enhancing effect of glucose in adjustment disorder and the extent to which bereave- humans is now well established.9 Glucose intake can ment precludes the diagnosis of depression. Many decrease the intake of micronutrients and is associated people now accept that those suffering the extremes of with obesity and diabetes. It also would not likely be depressed mood have a disorder for which treatment approved as a cognitive enhancer in children. Caffeine, might be appropriate. However, the characterization of like alcohol, certainly seems to fit some of the definitions paroxetine as a lifestyle drug when it is used to treat of a lifestyle drug, even if it is not usually considered social anxiety disorder suggests that there is less accep- one. People have a strong attachment to these drugs; tance of the idea that extreme shyness is a disorder.
attempts are often made to overcome the regulations Once there is acceptance of the need for treatment of concerning alcohol, and any attempt to regulate the use conditions at the extremes of the distribution curve, of caffeine would be unthinkable. When drugs are there is often debate about those that deviate less from developed that provide the benefits of these compounds the norm. As society accepts increasingly that depres- and none of their adverse effects, people will acquire sion is a disorder for which pharmacological treatment them by legal or illegal means. There needs to be a Rev Psychiatr Neurosci 2003;28(2)
debate on an appropriate regulatory framework for the those without psychopathology. However, with the use of mood and cognitive enhancers by healthy people.
development of compounds that enhance normal mood As far as regulatory policy is concerned, there are or cognition, but have limited or no adverse effects, the likely to be 4 different types of lifestyle drugs. potential positive aspects have to be considered. One • Drugs approved for specific indications (e.g., bald-
issue that has been raised is whether the increasing use ness or social anxiety disorder). They are classified as of lifestyle drugs is an attempt to homogenize society.2 lifestyle drugs because of a feeling in society, that Should those who are less smart or less happy accept the may or may not be justified, that pharmacotherapy mental state allocated to them by their genes and envi- for these types of problems is in some way frivolous. ronment, or should they be allowed to take compounds • Drugs, approved for specific indications, that are
that will move them toward the upper half of the distri- used for other purposes. At the moment, the main
bution curve? Is popping a pill for mild dysphoria an examples of this are the SSRIs, which are sometimes abrogation of personal responsibility? Is taking a pill to used in people who do not have a DSM disorder.
move mood from mildly happy to euphoric acceptable However, in the future, this class will probably in any circumstances, if the pill has no direct adverse include other drugs approved for the treatment of effects? Should parents be allowed to help their children mood or cognitive disorders but used by those any- gain a university education in part through pharma- where in the normal range to enhance their mood or cology if the only adverse effect to the parents and child cognitive ability. They will be used in this way be- is financial? Or should society be paying for all children cause some physicians will be willing to write pre- to take cognitive enhancers if ones without side effects scriptions for these drugs, even for people who do not have a disorder. They will also be taken by peo- Society has not to any great extent attempted to come ple who obtain them through illegal means. to grips with issues such as these. Meanwhile, there are • Drugs that have been used traditionally and are
increasing signs that more effective and less toxic therefore not usually thought of as lifestyle drugs but lifestyle drugs will be developed long before there is are taken for the purpose of altering mood or social any broad agreement that will enable rational and con- behaviour in people who may or may not be men- sistent regulation of them. This is a sharp contrast with tally healthy. This includes illegal drugs of abuse, as some other areas of research, such as genetics and well as those that are legally sanctioned, such as al- reproductive technologies, where the ethical and soci- etal implications of research developments, as well as • Natural products. Potential examples of this category
proposals for keeping regulations responsive to new include ascorbic acid and fish oils, but also include a discoveries, have been widely discussed.
wide range of other products, such as herbal extracts.
These are minimally regulated by governments un- References
less they are clearly toxic or specific claims are made Atkinson T. Lifestyle drug market booming. Nature Med 2002;8: by the manufacturer about their actions. Use of this type of product depends on information, sometimes Lexchin J. Lifestyle drugs: issues for debate. CMAJ 2001;164: correct, about their actions that is distributed by any- Gilbert D. Lifestyle drugs: Who will pay? Script report. London: one other than the manufacturer. Overall, the regu- lations are based more on factors such as traditional Campbell EJM, Scadding JG, Roberts RS. The concept of disease.
patterns of use and whether the product is synthe- Smith R. In search of "non-disease." BMJ 2002;324:883-5.
sized by living organisms or by drug companies than Brody S, Preut R, Schommer K, Schurmeyer TH. A randomized on consideration of the implications of the use of controlled trial of high dose ascorbic acid for reduction of blood lifestyle drugs for the individual and society.
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Brody S. High-dose ascorbic acid increases intercourse fre- tion of lifestyle drugs is developed, there has to be much quency and improves mood: a randomized controlled clinical more consideration of the desirability of enhancing men- trial. Biol Psychiatry 2002;52:371-4.
tal states to please the individual. Currently, the main Rose SPR. 'Smart Drugs': Do they work? Are they ethical? Willthey be legal? Nature Rev Neurosci 2002;3:975-9.
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J Psychiatry Neurosci 2003;28(2)

Source: http://www.cma.ca/publications/jpn/pg87.pdf