Modafinil monotherapy in poststroke depression.

Case Reports Modaﬁnil Monotherapy in Poststroke Depression S TEVEN G. S UGDEN , M.D. J AMES A. B OURGEOIS , O.D. , M.D. A lthough the incidence of cerebrovascular disease has stabilized, the number of stroke survivors increases as the acute management of stroke improves. 1 Poststroke depression is common; the risk for major depression is 10%–25%, while the risk for minor depression is 10%– 40%. 2 Poststroke depression is associated with excess dis- ability, poor rehabilitation outcomes, greater morbidity and mortality, and suicidality. 3 These complications may be ad- dressed with pharmacotherapy. 4 Modaﬁnil, a wakefulness-promoting agent, is ap- proved by the Food and Drug Administration for narco- lepsy. 5 There are case reports of off-label use of modaﬁnil for depression, including cases of treatment resistance and severe medical comorbidity. 6–8 Although the mechanism of action is unknown, the drug has norepinephrine agonist properties in the anterior hypothalamus. 9 We report a case of poststroke depression that was responsive to modaﬁnil treatment. Case Report Ms. A, an elderly woman, came in with a worsening head- ache that progressed to acute loss of consciousness. Her medical history included hypothyroidism, hyperlipidemia, hypertension, and abdominal hernia repair. She had a his- tory of bipolar I disorder treated with lithium carbonate, 600 mg/day. Her other medication was levothyroxine, 100 lg/day. The results of serum chemistries, a CBC, and mea- surements of thyroid-stimulating hormone and T 4 levels were found to be within normal limits. A computerized tomography (CT) scan showed a rup- Received April 10, 2003; revision received June 2, 2003; accepted June 16, 2003. From the Department of Psychiatry, University of California, Davis. Address reprint requests to Dr. Bourgeois, Department of Psychi- atry, University of California, Davis, 2230 Stockton Blvd., Sacramento, CA 95817; james.bourgeois@ucdmc.ucdavis. edu (e-mail). Copyright ᭧ 2004 The Academy of Psychosomatic Medicine. tured berry aneurysm on the basilar tip, so Ms. A under- went endovascular coiling. Her level of consciousness con- tinued to deteriorate. A repeat CT scan showed frontal lobe hydrocephalus; a right frontal ventriculostomy was per- formed and allowed to drain for 1 week. Postoperatively, Ms. A gradually regained consciousness but was disori- ented and could not follow directions. An MRI performed 16 days after presentation showed a coiled aneurysm at the basilar tip, an intraventricular hemorrhage with a right frontal ventricular peritoneal shunt, a right frontal he- matoma, a complex aneurysm of the left posterior com- munication artery, and irregularities in the left proximal communicating and middle cerebral arteries. Twenty-four days after Ms. A’s initial presentation, she began inpatient rehabilitation, where she was described as “apathetic and lethargic,” with poor participation in physical therapy. There were no reported symptoms of mania, anxiety, or psychosis. Ms. A was evaluated by the psychiatric consultation- liaison service. She was alert but disoriented to person, place, and time. Her affect was ﬂat. She did not engage in conversation and had sparse spontaneous speech. She was unable to complete any components of the Folstein Mini- Mental Status Examination (MMSE). She reported no sui- cidality or hallucinations. She was started on a trial of mo- daﬁnil, 100 mg/day; lithium was discontinued. After the third dose, she became more alert and spontaneously en- gaged in conversation. An MMSE after 10 days of moda- ﬁnil therapy revealed a score of 21. She was able to tolerate physical therapy and was subsequently discharged from rehabilitation 1 week early because of her functional gains. Two weeks after discharge, Ms. A’s mood symptoms were stable. She did not appear to be apathetic or to display vegetative symptoms, and she engaged in conversation spontaneously. There were no signs of mania or hypoma- nia. However, she and her family noted continued deﬁcits of her memory to which she required prompting. She was able to bathe, dress, and feed herself, but she required su- pervision. Her next score on the MMSE was 20. Psychosomatics 45:1, January-February 2004