Armodafinil induced mania in schizophrenia

To the Editor

Armodafinil is prescribed in narcolepsy, shiftwork sleep disorder and obstructive sleep apnoea (Stahl, 2011). It has also been used in bipolar depression, attention deficit hyperactivity disorder (ADHD) and for improving negative symptoms in schizophrenia. Adverse events include headache, nausea, anxiety and insomnia.

A 19-year-old female, who had paranoid schizophrenia (DSM –IV TR) of one and half year’s duration, was on treatment with risperidone 4mg/day and trihexyphenidyl 4mg/day for one year.

When first seen by us, she had paranoid delusions, auditory hallucinations and marked negative symptoms. Throughout the illness, she had no affective symptoms. There was significant daytime somnolence. There was no family history of mood disorder. She had gained 20kg of weight, from 76kg to 96kg, over a period of one year and her S.Prolactin level was 83ng/ml.

Her treatment was changed by us from risperidone 4mg/day and trihexyphenidyl 4mg/day to aripiprazole 30mg/day.

Her S.Prolactin level decreased to 34ng/ml and she lost 10kg of weight over two months. The negative symptoms and daytime somnolence persisted.

She was put on armodafinil 150mg/day for her somnolence. She developed mania within three days of this, and hence armodafinil was stopped and the manic symptoms remitted in 10 days. After stopping armodafinil, she again developed negative symptoms and somnolence in three months.

A year later, armodafinil was introduced in a dose of 50 mg/day, under close monitoring. With this change, her negative symptoms decreased, she started helping in household chores and her social behaviour improved.

In this case, armodafinil was first used for daytime somnolence. Within three days the patient developed full blown mania, which subsided in 10 days of stopping the drug. Her negative symptoms and daytime sleepiness had improved for three months after her armodafinil- induced mania had remitted a year earlier. This was the reason for armodafinil re-challenge in a much smaller dose under close monitoring. To our knowledge, there is no reported case of armodafinil-induced mania. After the re-challenge there was no recurrence of mania, there was sustained improvement in negative symptoms and daytime somnolence.

There is no evidence of improvement of negative symptoms, with armodafinil in schizophrenia (Bobo et al., 2011; Kane et al., 2012). The notable features in this case are substantial weight loss after change of medication, reduction in negative symptoms and somnolence, with low dose armodafinil. This is a unique case of armodafinil-induced mania in a patient with schizophrenia, who never had affective symptoms.