What are the medication treatment options for kleptomania?

Medication Treatment Options for Kleptomania

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment for kleptomania, with fluoxetine and paroxetine showing the most promising results based on available evidence. 1

Primary Medication Options

First-Line Treatments:

• SSRIs
  • Fluoxetine: Start at 20mg daily, may increase to 40-60mg daily as needed 1
  • Paroxetine: Start at 20mg daily, may increase to 40-60mg daily as needed 1
  • Escitalopram: Start at 10mg daily, may increase to 20mg daily after 4 weeks if needed 2

Second-Line Treatments:

• Mood Stabilizers
  • Divalproex sodium: Initial dosage 125mg twice daily, titrate to therapeutic blood level (40-90 mcg/mL) 3
  • Lithium: Dosage varies based on serum levels 3

Third-Line Treatments:

• Opioid Antagonists
  • Naltrexone: Has shown promise in some case reports 4

Treatment Algorithm

1. Initial Assessment:

   • Evaluate for comorbid psychiatric conditions (particularly mood disorders, anxiety disorders, and substance use disorders)
   • Rule out organic causes and medication side effects

2. First Treatment Trial:

   • Begin with an SSRI (fluoxetine or paroxetine preferred)
   • Start at low dose and titrate upward over 4-8 weeks
   • Target response: >50% reduction in stealing episodes

3. If Inadequate Response to First SSRI:

   • Switch to a different SSRI
   • Allow 8-12 weeks for full therapeutic effect

4. If Inadequate Response to Multiple SSRIs:

   • Consider mood stabilizer (divalproex sodium or lithium)
   • Monitor appropriate blood levels and side effects

5. For Treatment-Resistant Cases:

   • Consider naltrexone as augmentation
   • Consider combination therapy (SSRI + mood stabilizer)

Monitoring and Follow-up

• Regular assessment of stealing behaviors (frequency, intensity, triggers)
• Monitor for side effects specific to the medication class used
• For mood stabilizers: monitor complete blood count, liver enzymes, platelets, and therapeutic drug levels
• Evaluate for suicidal ideation, particularly when initiating or changing antidepressant therapy

Important Considerations

• Therapeutic Response: In open-label trials, approximately 79% of patients responded to SSRI treatment with significant reduction in stealing behaviors 2
• Relapse Prevention: Long-term maintenance therapy may be necessary as discontinuation can lead to relapse of kleptomanic behaviors 1
• Treatment Duration: Optimal duration is unclear, but similar to other impulse control disorders, 6-12 months of successful treatment before considering tapering

Conceptual Framework

Kleptomania was traditionally classified as an impulse control disorder but may be better understood as existing on a spectrum that includes features of:

• Obsessive-compulsive disorders (intrusive thoughts, ritualistic behaviors)
• Addictive disorders (craving, tension relief after stealing)
• Mood disorders (comorbidity with depression) 3

This conceptualization helps explain why different medication classes may be effective for different patients, depending on which neurobiological mechanism predominates in their presentation.

Pitfalls to Avoid

• Underdiagnosis: Kleptomania is often missed or misdiagnosed in clinical settings
• Focusing only on comorbid conditions: While treating comorbidities is important, specific treatment for kleptomania itself is necessary
• Premature discontinuation: Medication should be continued for adequate duration even after initial response
• Ignoring psychotherapy: Cognitive-behavioral therapy should be considered as an adjunct to medication for optimal outcomes 5