Vol 4, Iss 2: Letter to the Editor

Modafinil and Mania?

This is a very interesting case demonstrating the broad range in response in different individuals to the same medication. Modafinil is a cortical activator, and the therapeutic effects mostly benefit sleepiness, fatigue, executive dysfunction and motivational disorders. However, it appears to have an antidepressant effect in some patients, such as the case described by Patricia E Hogan, D.O. Any treatment that has an antidepressant effect can induce mania in some individuals. This patient seemed to be particularly susceptible to a manic side effect since she demonstrated a strong antidepressant response to a modest dose of modafinil, there was history compatible with bipolar illness, she had a family history of bipolar illness and geriatric patients sometimes demonstrate a strong response to low doses of medications. She was also on nefazodone and zaleplon during the first episode and nefazodone during the second episode, which may have also had mood effects in this patient.
I basically agree with the author's conclusion. This is an interesting case in which there is evidence that modafinil contributed to mania, especially since stopping the modafinil did appear to result in a rapid disappearance of mania. However, since modafinil clearly helped this patient's depression when she was treatment resistant to other therapies, I would continue this patient on modafinil with close monitoring and low doses, sometimes below 25 mg/day.
A similar issue has arisen with atomoxetine. Atomoxetine is FDA approved for the treatment of attention deficit/hyperactivity disorder and has no or limited antidepressant effects in most patients. However it does elevate the mood of some patients and rare cases of mania have been reported.

Robert C. Bransfield, MD
Red Bank, NJ