Monday, August 31, 2015

Provigil: the drug that helps you perform better

There is an article in the Atlantic called "The Rise of Work Doping" that talks about Provigil (modafinil) as a medication that enhances cognition with very few side effects. Medically, we use it to treat narcolepsy -- the uncontrollable urge to fall asleep. But I've also seen patients on it for depression -- often a desperation measure prescribed during a hospitalization. In terms of cognition and motivation, I haven't seen it do amazing things -- maybe the patient has more energy and functions a little better, but it's been no panacea for low motivation or cognitive jump-starting. There's a caveat here:   I've used very little of it for a very practical reason: the medication cause roughly $1000 for 30 pills (give or take a couple of hundred) and it's not a drug that insurances are eager to approve.

 I'd like to tell you something about the practice of psychiatry, or at least about my practice. I see a fair number of patients with mood disorders, and the mood disorders are often pretty easy to treat. The symptoms generally resolve (no, not for everyone, but a for a lot of people). And while many people get better and return to work and to a meaningful, active life, there are some people who stay stuck in a life they are disappointed with despite the resolution of the depressive symptoms. They remain unmotivated (especially for things they don't enjoy doing), may not return to work or do so in notably under-employed ways, and can find it hard to accomplish even little things, like cleaning up a bedroom or closet, or plowing through a to-do list, or organizing a vacation, or coping with a broken car/iphone/computer.   Or perhaps their moving along okay, but they aren't happy with their lives the way they are and just can't seem to do what's necessary to get life to change.

Often these people also have issues with attention to detail and organizing their lives.  They forget appointments, lose their keys and phones, and have trouble planning ahead: what we call Executive Function.  While stimulants may help these folks with concentration and energy, they don't seem to do much for helping with organizational skills.   So while I'm not interested in giving Provigil to healthy executives who want a raise, I am interested in knowing if you have tried it with your patients with Executive Dysfunction, and if it's been helpful to them?


Anonymous said...

I tried taking it but had to cease sine it gave me hypertension.

Anonymous said...

Over the years I have taken Provigil, Concerta, Ritalin, and now Vyvanse. Provigil and Concerta didn't do much. Ritalin was too intense. Vyvanse has worked the best.


Dinah said...

Could folks say what they are taking Provigil to address, and what symptoms it has helped with? I'm specifically interested in motivation/flexibility/organizational skills (executive function).

Anonymous said...

I'm not entirely sure why I was prescribed Provigil. I think my previous psychiatrist was trying to address the fact that I slept all day and also address executive function type stuff. It helped me stay awake more during the day, but I didn't see much effect on motivation, concentration, etc. I was on antidepressants at the same time I was taking Provigil, so maybe it just wasn't a good combo. Vyvanse has worked much better, for me anyway. I hated Ritalin because I would sit for hours plucking hairs out of my body. Thankfully, Vyvanse hasn't caused that lovely side effect. I've seen a few different psychiatrists and they have never said I had ADD, but they have all wanted to put me on stimulants. I'm not sure why. I guess they think I'm a little mixed up.


bluejonah said...

You touched on something I've been talked to about with my depressions: executive function. Could you maybe talk more about that? What, if anything, have you seen that a patient could do to try and return that functioning back to normal? I think this is my biggest problem with depression: the complete desperation to get motivated, but the absolute struggle it is to get "there". It's like I have to fight my brain to get moving on something. Have you, or anyone, heard patients talk about that? Do they find certain things useful? What about clinicians? Does meditation, CBT, or anything else seem to improve your patient's motivation? I took a class in Motivational Psychology once. LOL basically it boiled to "well... here's some interesting theories. but we don't really know anything". I got a D. lol Total waste of money. Anyway, thanks for any help the authors or readers can give to me. Much obliged.

Dinah said...

Ha! How ironic: I just saw that my original title for this post was "the drug that makes you preform better." I fixed it, two days late, and now I'm thinking that maybe I should take some Provigil and see if I perform better!

Anonymous said...

I haven't used provigil but I've used ritalin and adderall. Adderall jumped me out a severe depression - could not be alone becuase I couldn't keep myself alive, the next open hospital bed was already reserved in my name - in three days. However, the side effects were extreme and after a month or so, I couldn't continue taking it. I had stopped sleeping completely, stopped eating almost entirely, though I was feeling fine. But let's not forget it's basically straight amphetamines.

The other thing I want to bring up is the effect both ongoing or chronic depression and psychiatric meds can have on cognition. Years ago, in first grade, I tested out of reading at a college level and I've read on average 10-15 books a week until my 30s. Until. Depression, and meds. I am in remission now, but still on meds, and over the last 4-5 years of chronic and severe depression, my ability to read and think has dropped. I can't always find the words I want. I've read perhaps 10 books in the last 5 years. My comprehension is slow and my concentration is weak. My interest level is low. There's no question this was a result of the years of meds, some of which were inappropriate. There is no medication considered appropriate for treating those outcomes. My top notch psychiatrist and nuerologist agree there's nothing to do beyond wait, and hope that as my brain continues to heal, some of it comes back, but both acknowledge that could be that it never will. Ritalin, Vyanse, Provigil - they're not even meant to treat that.

PS "I see a fair number of patients with mood disorders, and the mood disorders are often pretty easy to treat." That explains much to me about some of your posts and opinions. Either you, or your patients, or a combination, must be quite self-selecting and you appear to see people will minor mental illness. For most people, mood disorders are not "often pretty easy to treat." This may be why you seem to disagree so strongly with many of your commentors. You simply treat a very different, very lucky, very well-off, and very small population. When you say "mood disorder" you're thinking an easily resolved bit of depression. When we read "mood disorder" we're thinking of the years of severe and ongoing treatment-resistent mood disorder hell that we and our friends experienced. It's surprsing to me that you, as the professional, doesn't recognize that. I guess your population is extremely limited and selected. It concerns me that you think you speak for the masses in our experiences of mental health - both professionals and patients.

Dinah said...

Anon: "Often" does not mean "always," so yes, some of my patients have exactly the problems you describe. And 20 years working in community mental health centers in the inner city. Mood disorders vary quite a bit with how disabling they are, but some patients are totally disabled (suicidal, unable to get out of bed) and go from extremely sick to fully functional. Prognosis seems to depend more on the course of illness than how sick people get at their sickest. Have you listened to Andrew Solomon's TED talk on depression? The illness he describes would hardly be described as 'mild,' but he's gone on to be an amazing writer, a phenomenal public speaker, and a dad. And just as the course of an illness will vary, so are the treatments offered -- is it the same thing to get weekly (or more) therapy in combination with close med management as it is to see a therapist monthly and a psychiatrist for 15 minutes four times a year? Maybe my patients do well because I'm an amazing psychiatrist? : )

Joel Hassman, MD said...

Why is a drug that is generic for several years at least still so highly priced? Because the company that made brand name Provigil (Modafinil), Cephalon, did exactly what Forrest did with Lexapro supplanting Celexa that quickly became generic, and the latter drug was just an enatiomer of the original medication. Same here per Nuvigil to Provigil, read the link:

The issue was solely profit, and now I hope that Cephalon truly reaps the consequences of overpricing their original product that had real efficacy and just watch the failed outcomes of their "Me TWO" junior.

By the way, is it really just me, or aren't we as psychiatrists seeing subtle problems with Lexapro that really haven't played out in intensity and frequency with Celexa. Umm, wasn't in fact Celexa, Citalopram, the primary med used in the infamous STAR*D study? So, why are so many psychiatrists either ignoring, rationalizing, or plain denying these consequences with Lexapro, being used as an average dose of 20mg that is equivalent to at least 60-80 mg of citalopram that is considered a consequential dosage by the FDA these past 3 years???

Sorry, I am asking people to be honest and candid, not what most people really can handle in threads that are allegedly commented in to help the public???

Ostracizing a corrupt company, now there is a concept, but, again, that requires at least some exertion of time and energy, maybe even some money. Can't really do that off a computer or phone screen, eh?!

I haven't written a script for Nuvigil in years now, and to respond to the pending retort "aren't you depriving a patient of an option just because of your bias", well, maybe, but, aren't I being equally hypocritical in writing for it if I don't believe in it in the first place?! The patient can certainly see another psychiatrist for a second opinion. Just careful what ya wish for, hmm?

And before you ask me why aren't I writing for Provigil, even generic, participate in the authorization process a couple of times and get back to me. Oh, and to note to readers how petty and cheap insurers are these days, they have refused me to write for hydroxyzine HCL recently, a $20 Rx. Why? Think about it when you read the next part of this sentence, that generic xanax is cheaper?

How screwed up is that logic, colleagues!!!???

Cue Alan Parsons' I Robot theme song when checking the box below...

RB said...

I take Provigil (modafinil) PRN for excessive daytime sleepiness refractory to cpap therapy for sleep apnea. The first several times I took it I noticed my vision was much sharper, my mood was upbeat and I stayed awake over 20 hrs. That didn't last past the first week except for the time staying awake. When I am very tired it is easy enough to nap on it. However, in general, it keeps me awake throughout the day with some nights keeping me up longer than I want.

It's problematic to take PRN because it is hard to know how tired you are going to be in a day yet you have to take it before noon if you wish to get to sleep at a decent bedtime. In addition it is very easy to build a tolerance to it. My friend takes it for narcolepsy and after about 5 years of daily use she is up to 400 mg a day.

As far as effects on cognition, it improves my short term memory, alertness, and attention span but not consistently. I've also noticed that I am somewhat more easily distracted if there is a lot going on around me than if I didn't take it.

With that said, I've never experienced improvements with it better than on my best days using caffeine. But at least it's much milder than caffeine on the way up (almost never jitters on it) and on the way down (I tend to crash hard after caffeine wears off but the come down on modafinil is much gentler). Note: Taking the two together is bad news; wired and jittery as heck with headaches and bruxism and awake over 24 hrs.

Dr. Hassman, I think the pricing of modafinil is obscene but I blame the military for this. I am competing with them for the drug and they seem to be willing to pay these prices. Btw, the approval process for me is fairly easy but annoying. Twice a year I have to take my CPAP machine into my physician's office so they can verify I have been 100% compliant with CPAP therapy for the past 30 days.

tracy said...

I know it's awful to bring tv shows in to the conversation and ttherefore, I an on two depressants, but did anyone see the old "Law And Order SVU" where provigal (sp) was a big past of the "plot"?

Joel Hassman, md said...

Consider this as an alternative?

Hope it is of interest.

Anonymous said...

Provigil was a lifesaver for me. I had such a difficult time treating my depression and my doctor at the time tried it. He proclaimed that it was by far the best anti-depressant in the world but it's not approved for it. He was right, but it wasn't PRN. I never had so much success with treatment.

Anonymous said...


Sure you've seen this lots of times, but from a country where ADHD is not diagnosed particularly often. Depression starting early twenties following major life stressors, SSRI's unimpressive, then good results on 'Reboxetine', Straterra like drug. Then after a few years on that, realising that only able to deal with 'executive function stuff' until I went to a Shrink brave enough to consider treating a middle aged white collar professional for adhd type symptoms - the remaining dysexecutive symptoms were generally blamed either on remaining depression and/or laziness/immaturity (the second part mostly me I guess, though a little bit of defensive narcissim still around I guess).

I've been trialed on the amphetamines, ritalin and modafinil. Modafinil is a weird cross between ritalin and amphetamine for me. Sorry but that's the best way I can describe it :) Amphetamines seem to help you with your frontal lobe stuff, but don't damp down as much (and that's what i prefer, as I suspect most adults do). Meanwhile Ritalin really numbs down the impulsivity, but you can be left feeling like the front part of the brain is weakened a bit too which sucks. The Modafinil seemed to be a bit of a DAT inhibitor (in fact I think it is), whilst still giving me a weird 'awakeness'; ultimately not as good as amphetamine or ritalin though. I think a NRI like reboxetine might also be underated for people with dysexecutive syndrome rather than full ADHD.

I think one of the things that I've realised with depression is that it hits you hard in lots of different cognitive functions e.g. processing speed, working memory, divided attention etc etc. But now it seems more and more likely that you can punch your executive function (for example) back towards your non depressed state by doing cognitive training after you've recovered from the episode of depression. Two of the sites I like - Lumosity and Posit Science might be better for those who have a 'purely caused by depression' dysexecutive syndrome; with adhd I suspect the biological environment is such that you need to improve that, and then when coming out of a depression you can train your abilities back to where you were before without adding too many stimulants. Lumosity is the better one to start out with because its fun, but Posit is the one where you really get to push yourself back to your best once you're ready to do so.

I know this is going to sound weird...but in cases where there is 'just a little bit of dysexecutive syndrome', I wonder if things like vitamin and mineral insufficiencies don't contribute; e.g. Vitamin D, B12, Magnesium deficiencies, or some weird MTHFR thing. Magnesium L-Threonate is working great for me. I'm going to leave out physical exercise because that is just unrealistic :)

Wow. That's a lot of crap. Guess I need a med check.


P.S seriously though, I know that this is an older post but, do you think you significantly beat the STARD rates of remission for example? I'm honestly curious to know. Let's put aside personality disorders for a moment - it just seems like it's pretty clear that for e.g. MDD, both meds and therapy 'cure' permanently about one third, and half would have been cured anyway. Maybe a third more get a significant benefit. Maybe a combination gives you slightly better rates. But then there's always a third who really struggle. Do you think perhaps Shrinks rather than GPs are significantly better at detecting the bipolar, add, autism etc. which may exist, and this is why you think they get better results? But how much better? I'd actually really really like to see a heads up trial between a 'gold standard' diagnosis and treatment arm versus community treatment arm (gold standard being lets say three shrinks, with med changes only occurring with the agreement of all three, a bit like that ADHD trial from canada a few years back).

Again, dammit.