CASE REPORT
Recovery from chronic fatigue syndrome with modafinil [U.S. brand name:
Provigil]

Hum Psychopharmacol Clin Exp 2004; 19: 63-64.

Douglas Turkington [1], Daniel Hedwat [1], Iain Rider [1] and
Allan H. Young [2,*]

Affiliations:
[1] Royal Victoria Infirmary, Newcastle upon Tyne, UK
[2] School of Neurology, Neurobiology and Psychiatry, University of
Newcastle upon Tyne, UK

* Correspondence to: Prof. Allan H. Young, Department of Psychiatry, Royal
Victoria Infirmary, Newcastle upon Tyne, NEI 4LP, UK. Tel: 0191 232 5131
ext 24473. Fax: 0191 227 5108. E-mail:
mailto:a.h.young@ncl.ac.uk

Copyright © 2004 John Wiley & Sons, Ltd.


Fair-Use Summary:
Chronic fatigue syndrome (CFS) is a syndrome in which the defining symptom
is marked physical and mental fatigue (Fukuda et al., 1994). The aetiology
and pathophysiology are as yet not determined. Treatment is often
unsatisfactory, and only cognitive behavioural therapy (CBT) and graded
exercise therapy (GET) have proved themselves to be of significant benefit,
for some patients, in a recent systematic review (Whiting et al., 2001). In
terms of pharmacological treatments, the antidepressant SSRI, fluoxetine,
is most commonly used, but has been shown to be of little or no benefit in
treating the fatigue of CFS in randomized controlled trials (Wearden et
al., 1998). Clearly, more effective treatments need to be identified.
Modafinil is a central nervous stimulant used in the treatment of
narcolepsy. There are as yet no reports of its use in treatment of CFS. The
case of a patient with severe CFS who made a good recovery with this drug
is reported.

Mr C is a 33-year-old man who first presented to his GP in 1987, age 19,
with a range of symptoms including severe fatigue, general malaise,
generalized aches and pains and poor sleep, suggestive of an acute viral
illness. During this acute illness, the patient was bed­bound for 2-3
weeks. He recovered sufficiently so that he was able to begin University as
planned, but relapsed and remained symptomatic for the next 13 years.
Investigations revealed only past Coxsackie B virus infection, and a
diagnosis of CFS was made.

Over the years, Mr C's illness appeared to follow a relapsing and remitting
course, leading to severe disability, the patient not being able to leave
the house or to work.

Mr C first sought psychiatric help in 1990, after which courses of
fluoxetine, and cognitive behavioural therapy were tried but not found
helpful. Over the next decade, only prescriptions of temazepam and
zopiclone, which improved Mr C's sleep, were found to be of significant
benefit. In 1998, Mr C's condition reached its nadir, his condition
deteriorating such that he was confined to a wheelchair, barely having the
energy to sit up and feed himself, for the next 18 months. In 2000, real
improvements began. Initially, symptoms of myalgia responded partially to
clonazepam, and a course of modafinil, at a dose of 200 mcg mane, was
successful in treating Mr C's debilitating fatigue, with energy levels
improved from 20% to 60% of optimum in the space of a few months. Mr C was
able to return to part-time work, and, after 13 years of illness, at last
to enjoy a good quality of life.

Recent research suggests that the normal safety fears in relation to
amphetamine-based stimulant use (occurrence of rebound phenomenon after
treatment withdrawal, and the development of tolerance and dependence with
continued use) do not seem to be of concern in relation to modafinil (US
Modafinil in Narcolepsy Multicenter Study Group, 2000). This would make
modafinil potentially useful in CFS, where stimulants are avoided due to
their potentially addictive properties. Whether patients with CFS would
need to take modafinil long term needs to be established.

Modafinil could be used as a short-term intervention, allowing a
therapeutic window in which psychotherapeutic interventions could be
applied, and dysfunctional cognitions could be challenged. Clearly, further
research, in the form of long-term, double-blind, randomized controlled
trials would be warranted in order to investigate the efficacy and safety
of modafinil as a treatment option for CFS.