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Abstract

Objective

To explore the concept of, ethics surrounding, and arguments for and against cosmetic psychiatry.

Conclusions

Cosmetic psychiatry may be defined as the science and practice of interventions that subjectively enhance the mental states of healthy people. Cosmetic medicine (including surgery) is a professionally and socially accepted part of contemporary medical practice; cosmetic psychiatry is not. Like cosmetic medicine, there are significant risks associated with cosmetic psychiatry. There is an urgent need for a broader conversation about this emerging clinical reality.

Keywords

cosmetic psychiatry cosmetic medicine cosmetic psychopharmacology neurocognitive enhancement nootropics

‘I’m sorry, but all this ADHD doesn’t add up’, wrote British journalist Dominic Lawson.¹ Lawson had probed the seemingly communicable spread of attention deficit hyperactivity disorder (ADHD) amongst celebrities and interrogated the validity of this phenomenon. Through a disease-centred lens, Lawson was arguably right to be sceptical. Through a cosmetic-centred lens, however, perhaps less so.

So-called aesthetic medicine is loosely defined as ‘all medical procedures aimed at improving the physical appearance and satisfaction of the patient’.² Most are more familiar with the analogous term ‘cosmetic medicine’, which includes cosmetic surgery. In cosmetic medicine, a diagnosis is not required for an intervention to be provided; pathophysiology nonessential; but patient satisfaction is paramount. Cosmetic interventions may include nutrition, drugs, blades, lasers, vacuums, needles and syringes.² There is an expanding array of such cosmetic interventions on offer, legally available and readily accessible, all intended to subjectively enhance the human physical condition. But what about subjective enhancement of the human mental condition?

Without defining the concept, Giannini first made the case for cosmetic psychiatry in 2004 when he argued for ‘treatment without diagnosis’.³ For clarity, cosmetic psychiatry may be defined as the science and practice of interventions that subjectively enhance the mental states of healthy people. ‘Positive psychiatry’⁴ is a related but different concept, defined as ‘the science and practice of psychiatry that focuses on psycho-bio-social study and promotion of wellbeing and health through enhancement of positive psychosocial factors in people with illnesses or disabilities as well as the community at large’.⁴ In Listening to Prozac, Peter Kramer coined the term ‘cosmetic psychopharmacology’⁵ after describing some patients who seemed ‘better than well’ when taking fluoxetine.⁵ In essence, Kramer described performance-enhancing drugs. According to ethnobotanist Terence McKenna, the consumption of psychotropic substances for the enhancement of human mental states is as old as human history itself;⁶ indeed, modern history provides several more recent examples^7–11 (see Table 1).

Table 1.

Examples of prominent individuals who have described subjective enhancement of the mental state from psychotropic substance use. Terence McKenna controversially proposed that human evolution from Homo erectus to Homo sapiens (with development of human consciousness, cognition and culture) was driven by consumption of psilocybin-containing mushrooms - the so-called ‘stoned ape theory’.⁶ More recently, and perhaps more plausibly, some anthropologists have hypothesised that humans may have evolved to ‘counter-exploit’ plant neurotoxins.⁷ Modern history provides several examples of the ‘counter-exploitation’ of neurotoxins in prominent, professionally successful people (see below). It is important to note that professional success or prowess does not necessarily equate to health or mental health; the degree to which several of the following individuals were, in fact, ‘mentally healthy’ remains debatable

	Father of psychoanalysis, Sigmund Freud, extolled the virtues of cocaine and regularly consumed the tropane alkaloid that provided him with an ‘… exhilaration and lasting euphoria’.⁹ Using cocaine, Freud reported ‘one senses an increase of self-control and feels more vigorous and more capable of work’⁹
	Though Freud advocated for the use of cocaine to enhance the mental states of healthy people, it is important to note that the historical record suggests Freud suffered recurrent bouts of depression. Some authors have written that Freud used cocaine to relieve his depression yet, as Epstein notes, cocaine may in fact worsen depression⁹
	Renowned cosmologist Carl Sagan was a long-time user and advocate for legalisation of cannabis: ‘… the illegality of cannabis is outrageous, an impediment to full utilisation of a drug which helps produce the serenity and insight, sensitivity and fellowship so desperately needed in this increasingly mad and dangerous world’.¹⁰ Sagan argued that cannabis use, in moderation, was safe and beneficial in healthy people¹⁰
	Importantly, whilst Sagan may have felt cannabis helped produce ‘serenity and insight’, more contemporary evidence suggests it may also cause the opposite to this including disturbed memory and judgement, anxiety and psychosis.^15,16
	Iconic American inventor, computer pioneer and founder of Apple, Steve Jobs, allegedly told his biographer that, ‘taking LSD was a profound experience, one of the most important things in my life’.¹¹ He appeared to attribute much of his entrepreneurial success to the mental state enhancements provided by the drug: ‘[LSD] reinforced my sense of what was important – creating great things instead of making money…’¹¹
	It is important to note that Jobs’ biographer had also described him as being ‘depressed’ at least once and described his personality in a way suggestive of high trait openness to experience – both aspects of his personal history that may have contributed to his use of tryptamines.
	In contemporary Silicon Valley, advocates for cosmetic psychedelic use remain strong. Entrepreneur and author, Tim Ferriss, is candid: ‘The billionaires I know, almost without exception, use hallucinogens on a regular basis. [They’re] trying to be very disruptive and look at the problems in the world… ask completely new questions’⁸
	Despite his apparent advocacy for tryptamine use as performance-enhancing tool in professionally successful people, it is important to note that Ferris has also been open about his own struggles with mental illness including depression. He has also advocated for psychedelic use in this context.

Alongside supplements,³ lights, needles and electricity, there exists a wide variety of molecules that may subjectively enhance the mental states of otherwise healthy people, in some circumstances, some of the time^3,12,13 (see Table 2). The question is, does psychiatry have a role in providing, guiding and supervising any of these?

Table 2.

Examples of possible ‘cosmetic psychiatry’ interventions (interventions that subjectively enhance the mental states of healthy people)

Type	Example	Examples of potential short-term beneficial effects	Examples of potential short-term adverse effects	Examples of potential long-term adverse effects
Nutritional supplements	Kava³	- Muscle relaxation	- Sedation	- Liver and kidney impairment
		- Sleep promotion	- Oral paraesthesias	- Haematological problems
		- Feelings of wellbeing and relaxation	- Ataxia	- Amotivation
	St Johns Wort^3,12	- Mood enhancement	- Serotonin toxicity (especially if used with other serotonergic drugs)	- Mania/hypomania
		- ‘A feeling of overall wellbeing… in people without depression’	- Rash, photosensitivity	- Drug interactions
			- Mania/hypomania	- Loss of efficacy
Drugs	Stimulants^{12–14,22,25} (e.g. dexamphetamine)	- Increased alertness and concentration	- Anxiety	- Movement disorder^25,26
		- Increased focus and learning	- Psychosis	- Worsening of mood⁹
		- Increased energy	- Loss of appetite	- Stunted growth (in children)
		- Mood enhancement	- Loss of weight	- Cardiovascular disease
		- Decreased appetite and weight loss (where this effect is perceived as beneficial)	- Hypertension/tachycardia	- Loss of efficacy
	Non-stimulant ‘nootropics’¹² (e.g. modafinil)		- Anxiety	- Deficits in slow-wave sleep and short-term memory²⁹
			- Loss of appetite	- ?Personality changes
			- Loss of weight
	Psychedelics^6,8,12,13	- Increased energy	- Psychosis^12,13	- Psychotic disorder
		- Increased creativity	- Altered thought processes and perceptions¹²	- Hallucinogen persisting perception disorder (HPPD)¹³
		- Improved sense of ‘connectedness’ with nature and others	- Anxiety	- Tolerance
		- Enhanced mood	- Hypertension, tachycardia¹²	- Loss of efficacy
		- Sense of overall wellbeing		- Financial costs
	Cannabinoids^10,15,16	- Reduced anxiety	- Psychosis	- Psychotic disorder^15,16
		- Feeling of relaxation and wellbeing	- Perceptual distortions	- Worsening anxiety disorder
		- Increased talkativeness	- Disturbance of memory/judgment	- Amotivation (e.g. ‘cannabis amotivation syndrome’)
		- ‘Serenity and insight, sensitivity and fellowship’¹⁰	- Anxiety
			- Postural hypotension
Electricity	Transcranial direct current stimulation (tDCS)¹⁷	- Improved gaming and eSports performance via putative neurocognitive enhancement	- Inefficacy	- Inefficacy
			- Pain	- Financial costs
			- Burns
			- Financial costs

The case for

The first argument is Descartian – why should there be cosmetic surgery but not cosmetic psychiatry? Why is it accepted that doctors may subjectively enhance the face of a healthy person, but not their mental state? Giannini argued psychiatry should rise above the disease-centred goal of ‘objective cure’³ to assist individuals attain the cosmetic-centred goal of ‘subjective perfection’.³ Ethicist Arthur Caplan argued ‘brain enhancement’¹⁴ through cosmetic psychopharmacology is an individual human right that, where appropriately informed, is a choice that should be free from the gatekeeping of doctors and governments.¹⁴ Caplan argued for people’s rights to ‘the best brains possible’, even opining that, ‘religious and secular cultures alike reward those who seek betterment’.¹⁴ On the grounds of so-called cognitive liberty, advocacy for legal access to cognitive-enhancing drugs is increasingly prevalent.¹⁵

It has been argued that the professionally guided, supervised use of psychotropics is safer and more effective than self-prescribed or recreational use.³ Indeed, the call for regulation of all psychotropic substances, as opposed to prohibition, is an old and arguably rational one. Given their medical training and psychopharmacological expertise, some psychiatrists may be optimally placed to mediate such regulation. Regarding non-pharmacological interventions, passing electricity into the brain is best professionally regulated; self-administered electroconvulsive therapy (ECT) has resulted in burns and skin grafting, without therapeuticity.¹⁶ Transcranial direct current stimulation (tDCS) is an increasingly popular performance-enhancing tool for gaming and eSports;¹⁷ unregulated use exposes consumers to risks of inefficacy and harms (e.g. burns) but also financial exploitation.

The benefits of cosmetic psychotropic use in those who serve society are well documented. Stimulants have long been used by sleep deprived soldiers, pilots and sailors, and have played an important role in several wars.¹⁸ Some military doctors have opined that, ‘the healthy human has vast untapped potential’ and that it would even be, ‘remiss if we did not seek to improve performance in sleep-restricted environments’.¹⁹ Former US president, Barack Obama, was suspected to use modafinil²⁰ and, under his administration, White House staffers reportedly used modafinil and z-drugs to optimise performance and sleep/wake cycles whilst working ‘around the clock on high-stakes issues’.²¹ Unsurprisingly, it has been asked if similar benefits may be derived from psychotropic use in sleep deprived doctors (e.g. improved attention and alertness leading to reduced errors, etc.).²² The ethics therein remain underexplored.

Finally, clarifying psychotropic use as cosmetic-centred rather than disease-centred may improve precision of mental health statistics and epidemiology which may optimise health policy and funding allocation. For example, many psychotropics currently require a specific diagnosis to be legally prescribed. Where a drug is cosmetically prescribed, but a diagnosis erroneously given so as to legally provide it (e.g. stimulant for subjective neurocognitive and energy enhancement, but diagnosis of ADHD provided), the prevalence of the putative disorder is falsely inflated. Indeed, recent data suggests that by year four of their course, up to 61.8% of US college students were offered prescription stimulants for non-medical use, and up to 41.5% had used them.²³ This issue may be partly responsible for ‘all this ADHD’¹ and consequent calls for the National Disability Insurance Scheme (NDIS) to cover it. Thus, rather than perpetuating an ‘epidemic’ of a previously relatively uncommon adulthood disorder, acceptance of cosmetic psychiatry may generate a wealth of useful data regarding psychotropic use in otherwise healthy people.

The case against

The first counterargument is Descartian – the body is not the mind. Surgically altering one’s face is merely renovating the shopfront, whereas chemically altering one’s mental state may appear to alter the very essence of one’s being (e.g. perhaps Kramer was physically listening to his patients, but hearing Prozac). Substance-related personality changes can occur in context of substance use disorders, especially when longstanding.²⁴ Numerous websites report substance-related personality changes, including with so-called smart drugs. Theoretically, such changes could be biologically mediated but substance-influenced role changes, distorted temperaments, changed interpersonal styles and altered psychosocial functioning could all hypothetically contribute.

Regarding access, the libertarian argument for free informed choices requires that people are sufficiently informed. Consider a thought experiment: the ‘cosmetic psychiatry clinic’. Even if a psychiatrist set up a ‘cosmetic psychiatric clinic’ with appropriate training, stringent safeguards, regulatory oversight and comprehensive capacity assessments for consent to mental-state-enhancing interventions in healthy people (e.g. stimulants), it would still require that individuals could provide sufficiently informed consent. Short-term effects of most commonly used psychotropics are well-known, long-term effects less so. Given the current paucity of knowledge regarding long-term adverse effects, sufficiently informed consent may therefore be impossible to provide. Some evidence suggests many short-term benefits of psychotropics are lost long-term;²⁵ other evidence suggests more serious potential harms. Long-term stimulant use (recreational or prescribed) has been associated with permanent movement disorders;^25,26 ketamine use associated with irreversible bladder damage;²⁷ SSRI use with permanent sexual dysfunction;²⁸ psychedelics and cannabinoids with chronic psychotic disorders.¹³ Though lacking firm data, some experts hypothesise long-term modafinil use is associated with deficits in slow-wave sleep and memory²⁹ and even cancer.³⁰ Such long-term associations are rarely discussed. Advocates for wider access to tryptamines and methylenedioxymethamphetamine (MDMA) hastily cite drug harms ranking studies³¹ to promote the safety of these substances. Ironically, according to these same studies, psychedelics and MDMA sit adjacent antipsychotics,³¹ molecules with tremendous potential for harms, especially long-term. There simply is no such thing as a neurochemical free lunch.

The specific area of psychotropic neurocognitive enhancement, so-called ‘neuroenhancement’,¹⁹ has been heavily debated. Chatterjee examined four key areas of concern including (a) impacts on character and individuality, (b) safety, (c) distributive justice (e.g. only the wealthy having access) and (d) coercion.²² The latter deserves further attention. In a neoliberal capitalist society, productivity and performance are crucial and anything that enhances these parameters, indispensable. If neuroenhancing drugs were made legally available and readily accessible, it is possible that employers or corporations may implicitly or even explicitly mandate them. In a market-driven culture where everyone uses neuroenhancement, those who do not may fall behind and potentially lose their employment removing any need for explicit mandates. Exploring this conundrum, Appell argued for both unencumbered legal access to psychotropic neuroenhancement, but also legal protections to ensure it remained uncoerced.³² However, even if appropriate regulatory safeguards were implemented, it is doubtful they would ensure complete protection – as evidenced by illegal breaches of regulations in finance, elite sports and gambling, etc. Similar concerns apply to university, research and other important areas such as schools and scholarships where psychotropic neuroenhancement may offer a putative advantage. In this context, cosmetic psychiatry emerges as a form of naive unfettered consumerism, a manifestation of a materialist society where the pursuit of more or better outweighs all other considerations.

Finally, one crucial counterargument is that cosmetic psychiatry is simply not psychiatry. Strictly interpreted, the RANZCP definition of psychiatrist suggests no role outside of ‘diagnosing and treating people with mental illness’.³³ The stay-in-your-lane argument is that psychiatrists are in the business of healing the sick, not bettering the well. This argument demands there be other, non-psychiatric, professionals who provide, guide and supervise mental-state-enhancing interventions in otherwise healthy people. If one accepts this argument, it dictates there be another term to describe the practice (e.g. ‘psychocosmesis’ or ‘mind-enhancing medicine') as cosmetic psychiatry is a contradiction in terms.

Conclusion

This paper is not about extolling the benefits of supplements, psychotropics, electricity or other potentially mental-state-enhancing interventions. Nor is it an advocacy piece for legalisation of use or access to them. It is about considering the ethics and reality of interventions, substance or otherwise, that subjectively enhance the mental states of healthy people and whether psychiatrists have any role in providing, guiding and supervising these. There are arguments either way.

Unlike cosmetic medicine, cosmetic psychiatry is yet to be socially and professionally accepted. Meanwhile, the pursuit of (both lay and professional) interventions that subjectively enhance the mental states of otherwise healthy individuals continues unabated. Cosmetic psychiatry is a conversation that urgently needs to be had.

Footnotes

Disclosure

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

William Lugg

References

Lawson

. I’m sorry, but all this ADHD doesn’t add up. London: The Times, 2023, https://www.thetimes.co.uk/article/all-this-adhd-doesnt-add-up-comment-vqvl9kqvn (February 5, 2023).

AAAM . What is aesthetic medicine? Aesthetic medicine: A booming discipline! American academy of aesthetic medicine, https://www.aaamed.org/aesthetic_med.php (2023).

Giannini

. The case for cosmetic psychiatry: treatment without diagnosis. Irvine, CA: Psychiatric Times, 2004, https://www.psychiatrictimes.com/view/case-cosmetic-psychiatry-treatment-without-diagnosis

Jeste

. Positive psychiatry comes of age. Int Psychogeriatr 2018; 30: 1735–1738.

Kramer

. Listening to Prozac: The landmark book about antidepressants and the remaking of the self. New York: Penguin Books, 1997.

McKenna

. Food of the gods: the search for the original tree of knowledge. USA: Bantam Doubleday Dell Publishing Group Inc, 1993.

Sullivan

Hagen

Hammerstein

. Revealing the paradox of drug reward in human evolution. Proc Royal Soc B Biological Sci 2008; 275: 1231–1241.

Fink

. When silicon valley takes LSD. Atlanta: CNN Business, https://money.cnn.com/2015/01/25/technology/lsd-psychedelics-silicon-valley/ (2015).

Epstein

Farrell

. “Miracle cures” in psychiatry. Current Psychiatry 2019; 18: 13–16.

10.

Sagan

CMX

. Marihuana reconsidered. USA: Harvard University Press, 1969.

11.

Isaacson

. Steve jobs. New York: Simon & Schuster, 2011.

12.

Taylor

Barnes

TRE

Young

. The Maudsley prescribing guidelines in psychiatry: 14th ed. West Sussex, UK: Wiley Blackwell, 2021.

13.

Lappin

Darke

Farrell

. Psychotogenic potential of prescribed drugs. Aust N Z J Psychiatry 2023; 57(6): 777–779.

14.

Caplan

. Is better best? Sci Am 2003; 289: 104–105.

15.

Blitz

. Freedom of thought for the extended mind: cognitive enhancement and the constitution.

16.

Adachi

Masumura

Arai

, et al. Self-administered electroconvulsive treatment with a homemade device. J Ect 2006; 22: 226–227.

17.

Machado

Travassos

Teixeira

, et al. Could tDCS be a potential performance-enhancing tool for acute neurocognitive modulation in esports? A perspective review. Int J Environ Res Pu 2021; 18: 3678.

18.

Andreas

. Drugs and war: What is the relationship? Annu Rev Polit Sci 2018; 22: 1–17.

19.

Russo

Maher

Campbell

, et al. Cosmetic neurology: The controversy over enhancing movement, mentation, and mood. Neurology 2005; 64: 1320.

20.

Kantrowitz

. The white House mystery drug. The Daily Beast, https://www.thedailybeast.com/the-white-house-mystery-drug (2017).

21.

Lee

Summers

. Several White House medical unit staffers describe pressure to hand out meds _ CNN Politics.pdf. CNN Politics, https://edition.cnn.com/2018/04/27/politics/ronny-jackson-medical-unit-ambien/index.html (2018).

22.

Chatterjee

. Cosmetic neurology. Neurology 2004; 63: 968–974.

23.

Garnier-Dykstra

Caldeira

Vincent

, et al. Nonmedical use of prescription stimulants during college: four-year trends in exposure opportunity, use, motives, and sources. J Am Coll Health 2012; 60: 226–234.

24.

American Psychiatric Association . Diagnostic and statistical manual of mental disorders, 5th ed., Text Revision. Washington, DC: American Psychiatric Association, 2022.

25.

Moncrieff

. A Straight Talking Introduction to Psychiatric Drugs the truth about how they work and how to come off them. 2nd ed. Monmouth, UK: PCCS Books, 2020.

26.

Nam

S-H

Lim

Park

. Stimulant induced movement disorders in attention deficit hyperactivity disorder. J Korean Acad Child Adolesc Psychiatry 2022; 33: 27–34.

27.

Srirangam

Mercer

. Ketamine bladder syndrome: an important differential diagnosis when assessing a patient with persistent lower urinary tract symptoms. BMJ Case Rep 2012; 2012: bcr2012006447.

28.

Bala

Nguyen

HMT

Hellstrom

WJG

. Post-SSRI sexual dysfunction: a literature review. Sex Medicine Rev 2018; 6: 29–34.

29.

Cox

. Is modafinil safe in the long term? London: The Guardian, 2013, https://www.theguardian.com/education/mortarboard/2013/may/31/is-modafinil-safe-in-long-term

30.

Morais

GCde F

Junior

, et al. Modafinil: a closer look at its theoretical toxicological potential. J Psychopharmacol 2023; 37: 945–947.

31.

Bonomo

Norman

Biondo

, et al. The Australian drug harms ranking study. J Psychopharmacol 2019; 33: 759–768.

32.

Appel

. When the boss turns pusher: a proposal for employee protections in the age of cosmetic neurology. J Med Ethics 2008; 34: 616.

33.

RANZCP . What’s a psychiatrist? Royal Australian and New Zealand college of psychiatrists (RANZCP), https://www.yourhealthinmind.org/psychiatry-explained/whats-a-psychiatrist (2021).

Cosmetic psychiatry: A concept in urgent need of consideration