Psychotic symptoms, including hallucinations, delusions and paranoia, have been reported during modafinil treatment. Most of the direct evidence comes from case reports, which can show that symptoms appeared after modafinil exposure but cannot prove that the drug caused every episode.
Controlled trials in people with schizophrenia provide a counterweight, showing no clear increase in worsening psychosis with modafinil compared with placebo, although the available evidence is limited and generally low quality (Ortiz-Orendain et al., 2019).
Key Takeaways
- Psychotic reactions have been reported during modafinil treatment, but their frequency among people who use modafinil is not known.
- Controlled trials in schizophrenia have not shown a clear increase in worsening psychosis compared with placebo.
What Does Modafinil-Associated Psychosis Look Like?
Two systematic reviews published in 2026 examined the available case literature on psychosis associated with modafinil.
| Sato et al. (2026) | Alkhatib et al. (2026) | |
|---|---|---|
| Cases reviewed | 24 patients from 21 articles | 9 cases from 7 articles |
| Hallucinations | 66.7% | 44.4% |
| Delusions | 58.3% | 44.4% |
| Agitation | — | 55.6% |
These figures describe the characteristics of published cases, not the proportion of modafinil users who experience these symptoms.
Can Psychosis Occur at Normal Modafinil Doses?
Reported psychotic episodes include people taking doses used therapeutically. Sato et al. (2026) reported a median modafinil dose of 250 mg/day among cases with available dose information, while Alkhatib et al. (2026) identified published cases involving doses from 100 to 400 mg/day.
Aytaş and Dilek Yalvaç (2015) described a woman without a reported previous psychiatric disorder who took modafinil to improve concentration and developed suspiciousness, agitation and psychotic symptoms after taking 100 mg/day.
DiSciullo et al. (2018) reported another case involving 100 mg/day in a patient with bipolar I depression who was already receiving mood-stabilising and antipsychotic treatment. Psychosis developed shortly after modafinil was added.
These reports show that modafinil-associated psychosis is not confined to overdose situations.
Does a Higher Dose Increase the Risk?
Sato et al. (2026) included an intentional overdose involving 12,000 mg of modafinil, but Alkhatib et al. (2026) found no clear dose-dependent pattern across the cases they reviewed.
The available case literature therefore cannot establish whether the probability of psychosis rises predictably as the modafinil dose increases.
Are People With Psychiatric Conditions More Vulnerable?
Alkhatib et al. (2026) observed that patients with a previous psychiatric history appeared more vulnerable among the cases they reviewed, while Sato et al. (2026) included patients with diagnoses such as schizophrenia, depression and bipolar disorder.
The current PROVIGIL prescribing information advises caution when modafinil is used in people with a history of psychosis, depression or mania. Postmarketing psychiatric reactions have included mania, delusions, hallucinations, suicidal ideation and aggression, and the label notes that many, but not all, affected patients had a previous psychiatric history.
A psychiatric history may therefore be clinically relevant, but the available evidence does not show how much it changes an individual’s risk.
What Have Studies in People With Schizophrenia Found?
A 2019 Cochrane review identified six trials involving 209 people with schizophrenia that reported worsening psychosis. Adding modafinil to antipsychotic treatment produced no clear difference from placebo, with a risk ratio of 0.91 and a 95% confidence interval of 0.28 to 2.98. The evidence was rated low quality (Ortiz-Orendain et al., 2019).
Andrade et al. (2015) also reviewed randomised trials of modafinil or armodafinil added to antipsychotic treatment and found no significant worsening of positive schizophrenia symptoms compared with placebo.
These studies were relatively small and short-term, so they cannot exclude an uncommon individual reaction. They do show that published case reports should not be interpreted as evidence that modafinil generally worsens psychosis in people with schizophrenia.
Can Sleep Deprivation Contribute to Psychotic Symptoms?
In a review of sleep-deprivation studies, Waters et al. (2018) found that prolonged wakefulness could produce perceptual distortions, hallucinations and disordered thinking, with delusions appearing after more prolonged periods without sleep.
This is relevant when modafinil is used to sustain wakefulness. The PROVIGIL prescribing information describes a healthy male volunteer who developed ideas of reference, paranoid delusions and auditory hallucinations while receiving repeated 600 mg doses of modafinil together with sleep deprivation. There was no evidence of psychosis 36 hours after the drug was discontinued.
Because both high-dose modafinil exposure and sleep deprivation were present, the case cannot isolate the contribution of either factor.
Why Might Modafinil Affect Psychotic Symptoms?
Volkow et al. (2009) used positron emission tomography to examine the effects of 200 and 400 mg doses of modafinil in 10 healthy men. Modafinil occupied dopamine transporters and increased extracellular dopamine in brain regions including the nucleus accumbens.
These effects provide a possible biological route through which modafinil could influence psychiatric symptoms in susceptible individuals. The study did not examine psychosis and does not establish dopamine transporter blockade as the mechanism responsible for the reported cases.
How Quickly Can Symptoms Appear?
Among the nine cases reviewed by Alkhatib et al. (2026), psychotic symptoms appeared between approximately 48 hours and 21 days after modafinil was started.
The available cases are too few and too varied to establish a predictable onset period.
How Were Reported Cases Managed?
In the Sato et al. (2026) review, modafinil or armodafinil was discontinued in 16 of 24 patients, while 18 received antipsychotic medication. Seventeen patients, or 70.8%, showed marked improvement. Because management differed between cases, that improvement cannot be attributed to discontinuation alone.
In the Alkhatib et al. (2026) review, modafinil was discontinued in all nine cases, with additional psychiatric treatment used when needed. Seven patients, or 77.8%, experienced complete symptom resolution, while the remaining two showed partial improvement during the available follow-up.
What We Still Do Not Know
There is no reliable estimate of how often modafinil-associated psychosis occurs. Reviews of published cases do not include a denominator showing how many people took modafinil without developing psychosis, so they cannot be used to calculate incidence.
It is also unclear which individuals are most susceptible. Psychiatric history may be relevant, but its effect cannot be quantified from the available reports. Sleep deprivation, other medications, other stimulants and recreational drugs can also complicate attempts to identify the cause of an individual episode.
What Should You Do If You Develop Hallucinations or Delusions While Taking Modafinil?
Hallucinations, delusions, severe paranoia, mania or major behavioural changes while taking modafinil warrant prompt medical assessment.
The PROVIGIL prescribing information advises clinicians to consider discontinuing modafinil when psychiatric symptoms develop in association with treatment. A person experiencing psychosis may also have difficulty recognising that their perceptions or beliefs have changed, making outside assessment especially important.
If symptoms involve severe agitation, suicidal behaviour, inability to remain safe or a risk of harm to another person, emergency medical care is appropriate.
References
Alkhatib, S., Akbani, I., Musmar, H., Maris, C., Chahal, J., Chughtai, N., Reese, M., & Nichols, J. (2026). Clinical presentation of modafinil associated psychosis and review of reported cases. Discover Neuroscience, 21, Article 91. https://doi.org/10.1186/s13064-026-00325-x
Andrade, C., Kisely, S., Monteiro, I., & Rao, S. (2015). Antipsychotic augmentation with modafinil or armodafinil for negative symptoms of schizophrenia: Systematic review and meta-analysis of randomized controlled trials. Journal of Psychiatric Research, 60, 14–21. https://doi.org/10.1016/j.jpsychires.2014.09.013
Aytaş, Ö., & Dilek Yalvaç, H. (2015). Modafinil-induced psychosis: A case report. Nöro Psikiyatri Arşivi, 52(1), 99–101. https://doi.org/10.5152/npa.2015.7160
DailyMed. (n.d.). PROVIGIL: Modafinil tablet. U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e16c26ad-7bc2-d155-3a5d-da83ad6492c8
DiSciullo, A. A., English, C. D., & Horn, W. T. (2018). Modafinil induced psychosis in a patient with bipolar 1 depression. Case Reports in Psychiatry, 2018, Article 3732958. https://doi.org/10.1155/2018/3732958
Ortiz-Orendain, J., Covarrubias-Castillo, S. A., Vazquez-Alvarez, A. O., Castiello-de Obeso, S., Arias Quiñones, G. E., Seegers, M., & Colunga-Lozano, L. E. (2019). Modafinil for people with schizophrenia or related disorders. Cochrane Database of Systematic Reviews, 2019(12), CD008661. https://doi.org/10.1002/14651858.CD008661.pub2
Sato, Y., Sakuma, A., & Tomita, H. (2026). Modafinil-associated psychosis: A systematic review of case characteristics and management strategies. Therapeutic Advances in Psychopharmacology, 16, 20451253261446554. https://doi.org/10.1177/20451253261446554
Volkow, N. D., Fowler, J. S., Logan, J., Alexoff, D., Zhu, W., Telang, F., Wang, G.-J., Jayne, M., Hooker, J. M., Wong, C., Hubbard, B., Carter, P., Warner, D., King, P., Shea, C., Xu, Y., Muench, L., & Apelskog-Torres, K. (2009). Effects of modafinil on dopamine and dopamine transporters in the male human brain: Clinical implications. JAMA, 301(11), 1148–1154. https://doi.org/10.1001/jama.2009.351
Waters, F., Chiu, V., Atkinson, A., & Blom, J. D. (2018). Severe sleep deprivation causes hallucinations and a gradual progression toward psychosis with increasing time awake. Frontiers in Psychiatry, 9, Article 303. https://doi.org/10.3389/fpsyt.2018.00303