Success, but at What Cost?

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

The patient, who was in his late 20's, was clearly very driven. He was a straight-A student from K-12, graduated from an Ivy League school with a 3.9 GPA, and proudly tells me that he works at a startup. He wakes up early every morning for his hour-long commute and works 12-hour days. Admirably, he makes sure to exercise for an hour each night after he gets home. Then, after he eats dinner, he even tries to spend a couple of hours with his girlfriend. When he finally gets to bed, he sleeps from about midnight to 5:30am. Ever since starting college, he has not gotten more than 6 hours of sleep a night.

He tells me he's been feeling more tired and less focused over the past year, a period coinciding with him gaining greater responsibilities at work. This lack of focus is not constant, and he tends to have the hardest time concentrating around 2-3pm, when he would often feel tired and sleepy. Not surprisingly, he wonders if he has ADHD and if a stimulant medication can help.

I tell him: "I can't really diagnose you with ADHD because there is no evidence of impairment when you were younger. Plus, most people really do need close to 8 hours of sleep, and almost everyone who gets less than 6 will eventually have trouble staying alert and focused during the day. I recommend that you try to sleep between 7 and 8 hours a night for a few months and see if things improve." He was both dismayed and somewhat defiant: "Look, I'm really busy, and I'm not about to compromise any aspects of my life. There's no way I'm going to work less or give up my workouts or not spend time with my girlfriend."

This was the patient that came to my mind when I was reading the New York Times article over the weekend about adult prescription stimulant abuse:

Elizabeth, a Long Island native in her late 20s, said that to not take Adderall while competitors did would be like playing tennis with a wood racket.

"It is necessary — necessary for survival of the best and the smartest and highest-achieving people," Elizabeth said. She spoke on the condition that she be identified only by her middle name. […]

Elizabeth’s sleep tracker was confused. Her nightly rests were so brief, the iPhone software thought they were just naps. It recorded her average sleep over nine months: from 4:17 a.m. until 7:42.

After founding her own health technology company, Elizabeth soon decided that working hard was not enough; she had to work harder, longer. Sleep went from an indulgence to an obstacle.

So she went to a psychiatrist and complained that she could not concentrate on work. She received a diagnosis of A.D.H.D. and a prescription for Adderall in about 10 minutes, she said.

"Friends of mine in finance, on Wall Street, were traders and had to start at 5 in the morning on top of their games — most of them were taking Adderall," Elizabeth said. "You can’t be the one who is the sluggish one."

I'm saddened that we live in a world where the founder of a health technology company doesn't seem to care about how sleeping 3.5 hours a night affects her own health. It seems very Kafkaesque and short-sighted to me. How did things get this way, to the point where "success" is defined by individual achievement and productivity above all else?

I found David Brooks's column from last week to be quite pertinent. He traced the changes in American society stemming from the late 1940s, when the generation who had suffered through the Great Depression and World War II let loose and embraced consumerism, transforming the culture from one of self-effacement and sacrifice to one of self-expression and indulgence:

But I would say that we have overshot the mark. We now live in a world in which commencement speakers tell students to trust themselves, listen to themselves, follow their passions, to glorify the Golden Figure inside. We now live in a culture of the Big Me, a culture of meritocracy where we promote ourselves and a social media culture where we broadcast highlight reels of our lives. What’s lost is the more balanced view, that we are splendidly endowed but also broken. And without that view, the whole logic of character-building falls apart. You build your career by building on your strengths, but you improve your character by trying to address your weaknesses.

Instead of "broken," I would've chosen "incomplete," but otherwise I agree with Brooks's main points. And speaking of a glorified Golden Figure, I thought I was reading a late April's Fool joke when CNN/Money ran an article last week titled: "Mark Zuckerberg only works 50 to 60 hours a week." Unfortunately, it was not a joke, and of course the author qualified Zuck's work hours with: "But he conceded that if the definition of 'work' were expanded, he'd be working his 'whole life.'" Is this the sort of role model that we want for our kids? Do we want a society where people are admired for driving themselves to extremes, and a lucky few will become fabulously wealthy, while many more get stressed out and sleep-deprived, and a certain regrettable percentage end up with depression, anxiety, or suicide?