a 44 year old single male , presented to our outpatient department with complaints of day time excessive sleepiness , lethargy , low mood and disturbed sleep at night for the past 3 months .
history revealed that these symptoms were triggered by the death of his father . on detailed evaluation
, it was found that he had been on treatment for his mental illness from 2005 .
the course of illness was continuous characterized by withdrawn behavior , preoccupation , fear , auditory hallucinations , referential delusions and decline in social and occupational functioning .
he was evaluated by a psychiatrist and started on psychotropics . during follow - up ,
the patient complained of episodes of depressed mood , anxiety and sleep disturbance , lethargy and sleepiness that affected his shift work , for which he was prescribed modafinil 200 mg , along with the antipsychotics risperidone 4 mg and amisulpride 400 mg .
the patient himself gradually increased the dose to overcome the drowsiness that interrupted his shift work .
he started with 100 mg every 3 - 4 h over a shift work of 12 h. for the last 6 months he was unable to overcome his sleepiness during work without modafinil 100 mg / h thus making a total of 1200 mg / day of modafinil which he used to obtain over the counter .
he claimed to have symptoms of worsening of lethargy , tremors of hands , anxiety and erratic sleep hours when he skipped modafinil , patient reported a sense of well - being only with the drug and with the above dose .
12.4 gm% ; , wbc count  6300 cells / mm ; platelet count  2.4 lakhs / mm ; , random blood sugar  122 mg / dl . his metabolic parameters including renal function , liver function , lipid profile were within normal limits .
an additional diagnosis of modafinil dependence syndrome ( dependence criteria as per dsm v ) was made in view of the tolerance , withdrawal , inability to cut down , progressive increase in the amount of drug over a longer period of time and craving .
the dose was tapered slowly over a period of 1 month with 100 mg every 2 - 3 days and started on bupropion .
he reported sleep disturbance , increased sense of body warmth , lethargy and low mood during the process of tapering the drug .
in literature , only one case study has been reported on modafinil dependence at higher doses . in our case report , the patient reported himself started consuming more tablets to increase the effects derived from modafinil and landed with dependence phenomenon .
unlike amphetamine and its derivatives , modafinil is said to act by mechanisms independent of dopminergic system which is involved in dependence phenomenon of sympathomimetics and opioids and hence is devoid of addiction potential .
however there are few recent studies reporting that modafinil also binds to dopamine receptors and also affects dopamine uptake by dopamine transporters in the neurons . increasing doses of modafinil
another study conducted to know about modfinil 's subjective and behavioral effects showed that modafinil increases rating scale of the addiction research center inventory ( arci ) as much as amphetamine .
modafinil dependence can be attributed to its dopamine uptake blockade thereby increasing its concentration in dopaminergic areas of brain .
overdose of modafinil is not safe ; as a central nervous system stimulant it is prone to cause insomnia , agitation , tachycardia , rise in blood pressure etc .
there are no controlled trials or reports available for the treatment of modafinil addiction . in this patient ,
we cross - tapered modafinil with bupropion because of its action on dopamine and norepinephrine reuptake inhibiton , thus producing an effect similar to that of modafinil with antidepressant activity .
modafinil is listed as a schedule iv drug in the united states for its restricted sale .
there is no regulation on modafinil sale which has to be revised to prevent its abuse .
it is widely purchased over the counter by night shift workers to increase work the efficiency without sleep .
though abuse potential is claimed to be less , it should be considered serious due to increased use of modafinil among youngsters .
our case report is one among the very few reports of modafinil dependence , it gives a call for the need of regulations on the sale of modafinil .
 modafinil , a non - amphetamine psychostimulant , is indicated for narcolepsy , shift work sleep disorder and severe obstructive sleep apnea syndrome . 
 modafinil is prescribed at the dose of 100 mg once in a day or as two doses , 12 h apart in a day . 
 it has also been found that it reduces cocaine dependence and withdrawal phenomenon . 
 modafinil is claimed to have very low liability for abuse and dependence . 
 here we report a rare case of modafinil dependence . 
CASE REPORT
DISCUSSION
CONCLUSION