Department of Psychiatry, University of Illinois Chicago, Chicago, Illinois, USA.
Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
Ann Clin Psychiatry. 2023 Aug;35(3):195-198. doi: 10.12788/acp.0113.
Bipolar depression is a serious neuropsychiatric disorder associated with a high risk of morbidity and suicidality. Standard antidepressants approved for treating major depressive disorder fail to exert efficacy in bipolar depression. Although 5 agents have been developed for the treatment of bipolar depression, treatment resistance is still observed in some patients, and requires off-label pharmacotherapy. Modafinil and armodafinil have been reported to improve treatment-resistant bipolar depression, but with inconsistent results.
We present a case of a 65-year-old woman with severe bipolar depression who failed to respond to electroconvulsive therapy and IV ketamine but later responded to high-dose armodafanil.
The patient responded to high-dose armodafinil (gradually titrated to 1,000 mg/d) and achieved remission with good tolerability for 5 years. Recently, she contracted COVID-19 and developed muscular weakness. After a lengthy workup, we became concerned for myopathy as an adverse effect from armodafinil. The patient's dose of armodafinil was significantly reduced and she subsequently became very depressed and functionally disabled before improving again when armodafinil 1,000 mg/d was reinstated.
We propose that some of the negative results seen in research of armodafinil for bipolar depression may be due to the use of low doses (100 to 200 mg/d), and higher doses may be needed for adequate response in treatment-resistant bipolar depression.
双相抑郁是一种严重的神经精神障碍，与高发病率和自杀风险相关。已批准用于治疗重度抑郁症的标准抗抑郁药在双相抑郁中无效。尽管已经开发了 5 种药物来治疗双相抑郁，但一些患者仍存在治疗抵抗，需要进行标签外药物治疗。莫达非尼和阿莫达非尼已被报道可改善治疗抵抗性双相抑郁，但结果不一致。
我们报告了一例 65 岁女性患者，患有严重的双相抑郁，电休克治疗和静脉注射氯胺酮治疗均无效，但后来对高剂量阿莫达非尼有反应。
患者对高剂量阿莫达非尼（逐渐滴定至 1000mg/d）有反应，5 年期间具有良好的耐受性并达到缓解。最近，她感染了 COVID-19 并出现肌肉无力。经过长时间的检查，我们担心肌病是阿莫达非尼的不良反应。患者的阿莫达非尼剂量显著降低，随后变得非常抑郁，功能障碍，在重新开始使用 1000mg/d 的阿莫达非尼后再次改善。
我们提出，阿莫达非尼治疗双相抑郁的研究中出现的一些阴性结果可能是由于使用低剂量（100-200mg/d）所致，对于治疗抵抗性双相抑郁，可能需要更高剂量才能获得充分反应。
