Sınava çalışmam gerekiyor, Ritalin mi içsem, Concerta mı?

medikritik Sa, 31/12/2019 - 15:26

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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