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Modafinil-Induced Mania in a Patient with Bipolar Affective Disorder

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August 5, 2007

To the Editor:

Modafinil has been approved for the treatment of excessive daytime sleepiness associated with narcolepsy, shift-work sleep disorder, and obstructive sleep apnea/hypopnea syndrome. The notable side effects of modafinil use are headache, nervousness, anxiety, insomnia, nausea, hypertension, and palpitations.1 Apart from its use to control sedation associated with certain antidepressants2 and neuroleptics,3 it has been used in the treatment of unipolar and bipolar depression as a single agent or as an augmenting agent.2,4,5 Modafinil has been reported to be rather safe in inducing manic switches while treating depression.2,6,7 However, some case reports suggest induction of mania with modafinil treatment.8-10 The following is a case report of mania induced by modafinil in a patient with bipolar affective disorder.

A 36-year-old man with a 6-year history of bipolar disorder type I who was in remission for the last 2 years on oxcarbazepine 600 mg/day maintenance therapy, presented to our outpatient department with complaints of decreased concentration and mild depression. He was prescribed modafinil 100 mg/day for 3 days to be increased to 200 mg/day on the fourth day. However, from the first day, the patient started taking modafinil 200 mg/day on his own and after 2 days developed florid mania. Modafinil was immediately stopped; oxcarbazepine was increased to 900 mg/day; and haloperidol 10 mg/day, trihexiphenidyl 4 mg/day, and clonazepam 2 mg/day was started. The patient achieved euthymia within 2 weeks; over the next 4 weeks, all medications except oxcarbazepine 900 mg/day were tapered off.

The temporal course of events in the present case suggests a modafinil-induced switch to mania even in the presence of a mood stabilizer. This calls for a cautious use of modafinil in bipolar depression even if the patient is on a mood stabilizer.

Sincerely,

Ravi C. Sharma, MD

Dr. Sharma is professor and head of the Department of Psychiatry at the Indira Gandhi Medical College & Hospital Shimla in Himachal Pradesh, India.

Disclosure: Dr. Sharma reports no affiliation with or financial interest in any organization that may pose a conflict of interest.

 

References

1. Stahl SM. Essential Psychopharmacology: The Prescriber’s Guide. Rev ed. 1st South Asian Edition. Daryaganj, New Delhi: Cambridge University Press India Pvt. Ltd.; 2007.
2. Menza MA, Kaufman KR, Castellanos A. Modafinil augmentation of antidepressant treatment in depression. J Clin Psychiatry. 2000;61(5):378-381.
3. Makela EH, Miller K, Cutlip WD 2nd. Three case reports of modafinil use in treating sedation induced by antipsychotic medications. J Clin Psychiatry. 2003;64(4):485-486.
4. Kaufman KR, Menza MA, Fitzsimmons A. Modafinil monotherapy in depression. Eur Psychiatry. 2002;17(3):167-169.
5. Frye MA, Grunze H, Suppes T, et al. A placebo-controlled evaluation of adjunctive modafinil in the treatment of bipolar depression. Am J Psychiatry. 2007;164(8):1242-1249.
6. Fernandes PP, Petty F. Modafinil for remitted bipolar depression with hypersomnia. Ann Pharmacother. 2003;37(12):1807-1809.
7. Berigan T. Modafinil treatment of excessive sedation associated with divalproex sodium. Can J Psychiatry. 2004;49(1):72-73.
8. Vorspan F, Warot D, Consoli A, Cohen D, Mazet P. Mania in a boy treated with modafinil for narcolepsy. Am J Psychiatry. 2005;162(4):813-814.
9. Ginsberg DL. Modafinil-associated mania. Primary Psychiatry. 2007;14(1):23-25.
10. Wolf J, Fiedler U, Anghelescu I, Schwertfeger N. Manic switch in a patient with treatment-resistant bipolar depression treated with modafinil. J Clin Psychiatry. 2006;67(11):1817.

Please send letters to the editor to Primary Psychiatry, c/o Norman Sussman, MD, 333 Hudson St., 7th Floor, New York, NY 10013; E-mail: lla@mblcommunications.com.

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