Can Abilify (aripiprazole) cause sexual impulsivity in patients, particularly those with a history of impulse control disorders or other psychiatric comorbidities?

Can Abilify Cause Sexual Impulsivity?

Yes, aripiprazole (Abilify) can cause sexual impulsivity and hypersexuality as a recognized adverse effect, and this risk is significant enough that the FDA issued a formal warning in 2016 about pathological gambling and other compulsive behaviors, including compulsive sexual urges. 1

FDA-Recognized Risk

• The FDA drug label explicitly warns that patients can experience intense urges, particularly for gambling, and the inability to control these urges while taking aripiprazole 1
• Compulsive sexual urges are specifically listed among the impulse control problems associated with aripiprazole, reported less frequently than gambling but still clinically significant 1
• Because patients may not recognize these behaviors as abnormal, prescribers must specifically ask patients or their caregivers about the development of new or intense compulsive sexual urges while being treated with aripiprazole 1
• The FDA recommends considering dose reduction or stopping the medication if a patient develops such urges 1

Clinical Evidence and Characteristics

• A systematic review of 59 cases found hypersexuality was the second most frequently reported impulsivity adverse effect of aripiprazole (after gambling), with the majority of cases (71%) occurring in males at an average daily dose of 11.63 mg 2
• These symptoms occurred both in patients who had previous problems with impulse control and those who did not 2
• In the majority of cases, symptoms appeared within 30 days after aripiprazole administration started and ceased within 30 days of discontinuation or dose decrease 2

Mechanism and Risk Factors

• Aripiprazole is unique among antipsychotics as it has high-affinity agonist properties for dopamine D2 and D3 receptors, which may enhance dopaminergic activity in the mesolimbic reward pathways 3
• The medication also has 5-HT1A partial agonist and 5-HT2A antagonist properties that may promote sexual activity 3
• Risk factors include: young age, male sex, previous history of impulse control disorders, substance use disorders, and tobacco use 3, 4

Clinical Management Algorithm

Pre-prescription assessment:

• Screen for any history of impulse control disorders, including gambling, compulsive shopping, binge eating, or hypersexuality 1, 2
• Assess for substance use disorders, as aripiprazole may increase compulsive substance use in patients with this history 5
• Document baseline sexual behavior patterns 6

Patient education and informed consent:

• Explicitly warn patients and caregivers about the risk of developing new or intensified compulsive sexual urges 1
• Explain that these behaviors may not be recognized as abnormal by the patient 1
• Emphasize the importance of immediately reporting any changes in sexual behavior or urges 2

Monitoring during treatment:

• At each visit, specifically ask about gambling urges, compulsive sexual urges, compulsive shopping, binge eating, or other impulsive behaviors 1
• Monitor more closely during the first 30 days of treatment when symptoms most commonly emerge 2
• Involve family members or caregivers in monitoring, as patients may not self-report these symptoms 1

If sexual impulsivity develops:

• First-line intervention: Reduce the aripiprazole dose or discontinue the medication entirely 1, 6
• Symptoms typically resolve within 30 days of dose reduction or discontinuation 2
• Switch to an alternative antipsychotic without dopamine agonist properties (such as risperidone or amisulpride) 3
• Do not assume the behavior is solely related to the underlying psychiatric disorder—aripiprazole-induced compulsive behaviors are a distinct adverse effect 1

Important Caveats

• Avoid aripiprazole in patients with a history of bipolar disorder and impulse control problems, as guidelines specifically recommend considering alternative medications in this population 7
• The compulsive behaviors can result in significant harm to the patient and others if not recognized, including relationship damage, financial problems, and legal consequences 1, 3
• Unlike other antipsychotic side effects, sexual impulsivity may be difficult for patients to discuss due to feelings of guilt or shame, requiring direct and specific questioning 3
• Some cases have reported not just increased sexual activity but also changes in sexual orientation or engagement in high-risk sexual behaviors (unprotected sex, sadomasochistic practices) 3