Aripiprazole-Induced Pathological Gambling

Traditionally, when speaking about addiction, the focus has been primarily on substance use disorders. However, if we accept that addictive disorders are fundamentally characterized by psychological dependence and negative consequences, it becomes clear that addiction is not confined to the consumption of chemical substances. Any behavior initially perceived as pleasurable can evolve into an addictive pattern when the individual loses control and persists despite harm. The issue lies not in the behavior itself but in the maladaptive relationship established with it, leading to interference in daily functioning.^1,2 Within this broader framework, behavioral addictions—particularly gambling disorder (GD)—have gained increasing recognition.^1,3

Case Report

We report the case of a 29-year-old man, with 12 years of formal education and currently unemployed. His family history included a third-degree relative with schizophrenia. He had a long-standing history of substance use, including cannabinoids during adolescence, regular cocaine use from his late twenties, and recent methamphetamine use shortly before admission.

He presented to the emergency department with his family due to behavioral disturbances and psychotic symptoms in the context of methamphetamine use. On evaluation, he showed referential thinking and persecutory delusional ideation, with no insight. Given the severity, involuntary hospitalization was required, and treatment with olanzapine, titrated up to 20 mg/day, was initiated. This led to complete remission of psychotic symptoms, and he was discharged after 10 days. At follow-up, due to marked hyperphagia, a switch to aripiprazole was recommended.

Within weeks of starting aripiprazole, the patient developed a new-onset, compulsive gambling pattern, spending excessive time and money on slot machines. There was no personal or family history of pathological gambling, and a clear chronological relationship was identified between aripiprazole initiation and symptom onset. The behavior persisted until the medication was discontinued, after which the gambling urges progressively resolved.

Discussion

Dopamine plays a central role in reward learning and reinforcement through the mesocorticolimbic pathway, and excessive dopaminergic stimulation—pharmacologic or behavioral—can lead to loss of control over reward-seeking behaviors.^4,5 Although uncommon, medication-induced GD is clinically relevant. Dopamine replacement therapy in Parkinson disease is known to impair impulse control, producing behaviors such as pathological gambling, hypersexuality, compulsive shopping, and binge eating. The prevalence of impulse control disorders in this population ranges from 3.5% to 13.6%, with GD specifically affecting 2.3%–8% of treated patients.³

Large-scale studies show a strong association between GD and dopamine agonists such as pramipexole and ropinirole, both selective for D3 receptors.⁶ Activation of D2 and D3 receptors in the striatum likely contributes to increased addictive and impulsive behaviors. Despite its rarity, the true incidence of medication-induced GD is probably underestimated due to lack of recognition.⁷

Postmarketing pharmacovigilance data have shown similar associations with aripiprazole, a partial D2/D3 agonist.⁸ Health Canada and the US Food and Drug Administration have issued warnings about impulse control disorders related to aripiprazole, including gambling, with reported risk ratios from 5.23 to 16.39.⁹ The mechanism is thought to involve overstimulation of D3 receptors in the ventral striatum and altered reward prediction error signaling, resulting in impulsivity and reduced inhibitory control.^4,10,11

Recognizing this phenomenon is essential, as it remains underreported. Clinicians should inform patients and families of this risk before initiating treatment, particularly in individuals with psychiatric or substance use comorbidities.^2,12 In suspected cases, reducing the dose or discontinuing the offending agent typically leads to remission, while persistent symptoms may respond to cognitive-behavioral therapy or pharmacologic options such as naltrexone, though evidence is limited.¹³

Article Information

Published Online: May 7, 2026. https://doi.org/10.4088/PCC.25cr04140
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(3):25cr04140
Submitted: November 15, 2025; accepted January 7, 2026.
To Cite: Ribeiro M, Lourenço A, Chaves I. Aripiprazole-induced pathological gambling. Prim Care Companion CNS Disord 2026;28(3):25cr04140.
Author Affiliations: Department of Psychiatry, Unidade Local de Saúde de Santa Maria, Lisbon, Portugal (all authors).
Corresponding Author: Marta Loureiro Ribeiro, MD, Department of Psychiatry, Unidade Local de Saúde de Santa Maria, Lisbon, Portugal ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Patient Consent: Consent was obtained from the patient to publish the case report, and information has been de-identified to protect patient anonymity.