Sınava çalışmam gerekiyor, Ritalin mi içsem, Concerta mı?

Psikiyatri Uzmanı Çağdaş Yokuşoğlu

            Ritalin ve Concerta ticari isimli ilaçlar metilfenidat
isimli etken maddeyi içeren, dikkat eksikliği ve hiperaktivite bozukluğunun
(DEHB? sağaltımında kullanılan, uyarıcı özellikler taşıyan psikostimulan
ilaçlardır. Bu ilaçları internlük döneminde sadece farmakoloji dersinde değil,
aynı zamanda arkadaş ortamında kullanımlarıyla aşina olmuştum. Bazı
arkadaşlarımız bir şekilde bu ilaçlardan birini temin edip kullanıyorlardı.
Daha sonra psikiyatristlik dönemimde birçok internün benden bu ilaçları yazmamı
talep ettiğini ve onları reddettiğimi anımsıyorum. Ancak yine bu taleple gelen
birçok öğrenciye ilk kez dikkat eksikliği hiperaktivite bozukluğu tanısı
koyduğumu da biliyorum.

            Dikkat eksikliği, vitamin B12 eksikliği, kansızlık,
tiroid hormonlarının fazla üretilmesi gibi tıbbi sebeplerin bir sonucu
olabileceği gibi, DEHB, depresyon, kaygı bozuklukları, uykusuzluk gibi birçok
psikiyatrik durumun sonucu da olabilir. Bu tür hastalık ve durumların sağaltımı
birbirinden farklıdır. Bu sebeple dikkat eksikliğini düzeltmek için bir kişiye
metilfenidat başlanmadan önce bu durumların ayırıcı tanısının araştırılması
gerekir. DEHB dışındaki durumlar metilfenidat sağaltımı etki etmeyecek, hatta
kaygı bozukluğunda durumu kötüleştirebilecektir. Bununla beraber metilfenidat
bir psikiyatrik bozuklukta tedavi edici etkisi en yüksek ilaç gruplarından
biridir. DEHB’si olan kişilerde belirgin düzelmenin görülmesi üzerine halk
arasında söz konusu ilaç mucizevi olarak algılanabilmekte ve bu sebeple
psikiyatri polikliniğine sıklıkla bu ilacın yazılması talebiyle başvurulabilmektedır.
Psikiyatristler ise ilacın kırmızı reçteye tabi olması sebebiyle metilfenidat
reçete etmekte temkinli davranmakta, hatta bazen DEHB’si olan kişileri bile bu
sağaltımdan mahrum bırakabilmektedir.

       YARARI YOK, ZARARI ÇOK

     Yukarıda çizilen tablonun sonucu olarak, önemli bir sınava çalışan öğrenciler (örn. tıpta uzmanlık sınavına çalışan internler, diş hekimliği uzmanlık sınavına çalışan diş hekimliği öğrencileri ve tez döneminde olan doktora öğrencileri) bilişsel performanslarını arttırmak için bu ilacı talep etmektedir. Peki metilfenidat DEHB’si olmayan sağlıklı bir insanda gerçekten bilişsel performansı arttırabilir mi? Öncelikle bu ilacın sağlıklı bir bireyde bilişsel performanıs arttırmak için kullanılması, ilacın kötüye kullanılmasıdır. Ayrıca bu ilacın sağlıklı bireylerin bilişsel performansı ölçen test sonuçlarını olumlu etkilemediği gösterilmiştir (1). Bu sebeple sağlıklı bir bireyin ilacı kullanmak istemesinin mantıklı bir sebebi yoktur. Yararı olmayan bir ilacı kullanmak istemek ayrıca yan etki riskini göze almaktır. Bu ilaçların sık karşılaşılan yan etkileri arasında, uykusuzluk, iştah azalması, sinirlilik bulunur. Ayrıca kısa salımlı format olan ritalinin burundan çekilmek gibi, kafayı bulmak amaçlı kullanımları bildirilmiştir.

İŞE YARASAYDI TAVSİYE EDER MİYDİK?

Peki
bu ilacın bilişsel performansı arttırıcı etkisi olsaydı metilfenidat talebiyle
gelen kişilere psikiyatristler olarak metilfenidat yazmalı mıydık? Tıbbın
birincil ilkesi önce zarar vermedir. Hastalık halinde olmayan birisine, sırf
performansını arttırsın diye, ilaç olarak kullanılan ve yan etkisi olan bir
molekülü reçete etmek tıp etiğine aykırıdır. Ayrıca Sağlık Bakanlığı tarafından
ruhsatlandırılmayan bir durumda ilacın önerilmesi, hekim açısından suçtur.
Durumun bir de eşitlik ilkesi açısından değerlendirilmesi gerekir. Sağlık
hizmetlerine ulaşım, ülkemizde sosyal devletin gelişmemiş olmasından ötürü
eşitsizdir. Böyle bir ortamda sağlıklı bir bireyin, sıralama sınavında daha iyi
sonuç alabilmek adına, bilişsel perofrmansı arttırıcı bir ilaç kullanması,
tıpkı olimpiyatlarda doping kullanan bir atletin durumu gibidir ve haksız
rekabete yol açar. Bir hekimin haksız rekabete alet olması ise kabul edilemez
bir durumdur. Doğru ilacın, uygun durumda, doğru bir şekilde kullanılması
dileğimle tüm okuyuculara ve hastalarımıza iyi yıllar dilerim!

DİPNOT:
S. Batistela, et al. (2016). Methylphenidate As A Cognitive Enhancer In Healthy Young People. . Dementia & Neuropsychologia, sf: 134-142.

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Da Reduslim Glykogen synthetisiert, das für die Übermittlung eines Sättigungssignals an das Gehirn verantwortlich ist, kommt es zu einer natürlichen Appetitminderung und einem Schutz vor übermäßigem
Essen, so dass mit der Zeit der Bedarf an Lebensmitteln mit hohem
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Dieses Medikament hat alle notwendigen klinischen Studien bestanden, die
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die meisten Männer betrachten übergewichtige Frauen als nicht attraktiv.

Unsere Testerin konnte zwar keinen zweistelligen Gewichtsverlust verzeichnen, dennoch war Romy mit dem Ergebnis mehr als zufrieden. Die
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den Stoffwechsel hat bzw. den Sättigungsprozess, mag das Abnehmen um eine Spur einfacher.

Mein Stoffwechsel scheint in einen nicht vorhandenen Modus verfallen zu sein. Eine
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Hersteller verantwortlich Hersteller müssen im Zulassungsverfahren klinische Studien vorlegen. Vertrauenswürdige Verkäufer garantieren die Wirksamkeit dieses Produkts durch zahlreiche Zertifikate und Qualitätsaussagen. Der
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Erfolge auf Basis seiner natürlicher Zusammensetzung und
Kombination an Zutaten. Anja hat bereits mehrfach probiert, mit diversen Präparaten Gewicht zu verlieren, bislang gab es aber keine nennenswerten Erfolge.
Dank dessen kam meine Bestellung pünktlich und in gutem Zustand an. Ich nehme es jetzt seit einer Woche und das Gute daran ist, dass es
keine Nebenwirkungen hat. Während die Reduslim
Einnahme ohne Komplikationen verlief und auch keine Nebenwirkungen auftraten,
konnte unsere Probandin zu diesem Zeitpunkt einen Gewichtsverlust von 1,2 Kilogramm beobachten. Aussagen lassen sich auf der
Verkaufsseite des Herstellers finden und suggerieren,
dass sich mit dem Nahrungsergänzungsmittel ein effektiver Gewichtsverlust erzielen lässt.
Die Art der Diät kann aber den Gewichtsverlust beeinflussen. Er ist in vielen Nahrungsergänzungsmitteln zur Gewichtsreduzierung enthalten, aber es gibt nur sehr wenig Forschung darüber.
Die Forschung über die Vorteile von Carnitin bei der Gewichtsabnahme ist jedoch uneinheitlich.
Zu viel Carnitin kann Übelkeit, Erbrechen, Durchfall und einen fischigen Körpergeruch verursachen. Denn das Aussehen des
Einzelnen wandelt sich mit jedem Lebensjahr zunehmend.
Da wir uns aber nicht vollkommen auf die Aussagen des Herstellers
verlassen wollen, haben wir das Präparat einem Selbsttest unterzogen.
Ob sich die Aussagen des Herstellers auch in der Praxis bewahrheiten würden, können Sie in unserer ganz persönlichen, nun nachfolgenden Reduslim Erfahrung einmal nachlesen.

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