Case Report

Mr. B. is a 33-year-old non-smoker, African-American male with a 10-year history of schizoaffective disorder, bipolar type. He gained over 100 lbs over several years of treatment on a number of antipsychotic agents including haloperidol, risperidone, olanzapine, quetiapine, and finally, clozapine. Clozapine was initiated because of persistent psychotic symptoms and mood instability. Although Mr. B. exhibited excellent improvement in psychotic symptoms and mood instability, he experienced severe side effects from clozapine (i.e., sedation, fatigue, and weight gain), which greatly interfered with his ability to function in his college courses. As a result, modafinil 200 mg/day was initiated 6 months into clozapine treatment, and was tolerated without any adverse events for 3 years. During the first year, on the combination of clozapine and modafinil alone, Mr. B. experienced a weight loss of 40 lbs (from 280 lbs to 240 lbs) and a reduction in BMI of 5.08 Kg/m² (from 35.52 Kg/m² to 30.44 Kg/m²). He had not altered his diet nor increased his exercise routine during this period. Mr. B. continued on the combination of clozapine and modafinil for another 2 years. Throughout the 3-year period, fasting glucose (range 92 mg/dl to 94 mg/dl) and vital signs, including blood pressure (systolic blood pressure range 114–124mmHg; diastolic blood pressure range 60–71mmHg) and pulse, remained stable and within normal limits. After 3 years on the combination of clozapine and modafinil, his weight stabilized at 230 lbs (BMI = 29.59 Kg/m²). However, restrictions were placed on modafinil prescriptions by the Medicaid Formulary and modafinil was discontinued. This resulted in a 30-lb weight gain over 6 months, without significant change in mood or psychiatric symptoms. Modafinil was restarted with the aid of modafinil samples and resulted in a 10-lb weight loss over a 6-week period.