So let me say up front that this is a Rant, one inspired by the fifth young go-getter this week to walk across my threshold demanding I diagnose him with AD(H)D and prescribe him Adderall to get him through his dissertation/term paper/research proposal/whatever.

In my (not so) humble opinion, AD(H)D is not so much a disease (in the sense of a physiologic malfunction) as an unfortunate interaction of personality x environment.  Certain personality types just don’t do well with being required to sit in a chair for 8 hours a day.  A lot of those same people would probably do phenomenally well at running around outside spearing buffalo (Kuo and Taylor, ), but sadly for them, that’s not the environment in which they find themselves.

So, we have medication that can alter these people’s brains so they conform more acceptably to the society where they do find themselves.  We could have another very long and involved discussion about whether that’s a good choice or not but my feeling is, if a pill is the difference between good function and borderline or poor function, then please, weigh the pros and cons and make your own decision.  It’s your brain.  Not my business to dictate whether you ‘need’ it or not.

What I really don’t like is the cultural apparatus that is telling us the suboptimally attentive have a Disease, because the only legitimate reason to take a drug is if you have a Disease, and therefore that these people who take stimulants so they can function more effectively at work or school must have a Disease, because that is the only socially acceptable way that they can take their medication. 

And what I really, really don’t like is that as a physician I am being put in the middle of this.  I am being told that the only way these people can have their medication is if I diagnose them with a Disease and prescribe them the medication to Treat it.  There’s no box to check that says “This could help you do better than you are doing now, and I don’t mind if you take it, so long as you understand the risks and benefits.”  There’s only the Disease box and the No-Disease box.  And I can’t give out the drug unless I check the right box.

The thing about treating this Disease with stimulants is that, in the right dosage and formulation, they are going to be performance enhancers for most people.  How many thousands of students and professional writers have used a jot of speed to get them through that important deadline?  I’m currently working in our university’s student health center, where I see a lot of people who are coming to me for stimulants so they can make their already excellent function even better.  I honestly do not mind if people want to take brain-altering chemicals to help them write their papers – I’m swigging a bolt of caffeine as I write this post – but I do get a squicky feeling when I’m asked to write a doctor’s note about their ‘disease’ and a prescription so that they can ‘treat’ it.

So in my perfect world there would be public recognition of the wide latitude of uses for psychotropic medications, the terribly broad and nonspecific symptom clusters that constitute what we refer to as psychiatric disease, and the many reasons why people might want to take a drug that improves their ability to get their work done (see some interesting viewpoints on this issue from Nature and the Guardian) - even if their current abilities are well within the broad range of normal.  Will the public accept the availability of a smorgasbord of designer psychotropics for your business and recreational neuroenhancement needs?  Maybe, maybe not.  But please, let’s stop putting doctors in the middle by maintaining the fiction of a ‘disease’ for which stimulants are the ‘cure.’