The researchers retrospectively described three young men with online gambling disorder, each of whom was prescribed a combination of fluoxetine and risperidone, alongside cognitive behavioral therapy (CBT) and high-frequency repetitive transcranial magnetic stimulation (rTMS). Over 22–23 days of inpatient treatment, all patients showed improvement on key psychometric scales and cessation of gambling behavior. Post-discharge follow-up lasting from 16 to 22 months confirmed that the effect was sustained.
Why online gambling has become a public health problem
Since the first online casino appeared in the 1990s, the industry has seen explosive growth. According to large meta-analyses, gambling disorder affects from 0.2% to 2.1% of the population. The social consequences are often catastrophic: a spiral of debt, family conflicts, job loss or dropping out of school, and, in extreme cases, suicidal behavior. At the same time, there is still no approved pharmacotherapy for this disorder.
Authors’ aim and study design
The aim of the publication was to share clinical experience with combined pharmacotherapy in patients for whom psychotherapy alone had previously been ineffective. The design is a retrospective description of a three-case series. Data were drawn from inpatient observations and psychometric scales. Length of inpatient stay was 22–23 days, and post-discharge follow-up lasted from 16 to 22 months.
A uniform assessment battery for all patients
Diagnosis was made according to DSM-5 criteria. Psychometrics included four instruments:
• SCL-90 (Symptom Checklist-90; normal is <67 points);
• HAM-A (Hamilton Anxiety Rating Scale);
• HAM-D (Hamilton Depression Rating Scale);
• PSQI (Pittsburgh Sleep Quality Index; clinically significant impairment at a score above 5).
Scores were recorded before treatment and prior to discharge. Routine laboratory tests and instrumental examinations in all three revealed no clinically significant abnormalities.
Debt, anxiety, and suicidal ideation in a 26-year-old gambler
The first patient had been gambling online for more than three years, dropped out of school, accumulated significant debt, and had suicidal ideation without attempts. A six-month course of psychotherapy in another inpatient facility produced no benefit. On admission: SCL-90 — 158, HAM-A — 17, HAM-D — 10, PSQI — 13. He was prescribed fluoxetine 40 mg/day, risperidone 1 mg at bedtime, and lorazepam 0.5 mg at bedtime. In parallel, he received 6 CBT sessions and 22 rTMS sessions (10 Hz over the left dorsolateral prefrontal cortex). By discharge, scores had improved markedly: SCL-90 — 110, HAM-A — 8, HAM-D — 6, PSQI — 4. Remission was maintained for 22 months with regular medication use.
Six years of uncontrolled betting and irritability when trying to stop
The second patient, 27 years old, started by buying lottery tickets for the World Cup and then lost control. Without gambling, he felt bored and weak, and he became aggressive when family members made any remarks. Before treatment: SCL-90 — 172, HAM-A — 14, HAM-D — 19, PSQI — 13. The regimen included fluoxetine 40 mg/day and risperidone 1 mg at bedtime, CBT, and rTMS. By discharge: SCL-90 — 122, HAM-A — 2, HAM-D — 6, PSQI — 2. Over 19 months of follow-up, no relapses were recorded.
Relapse after attempts to quit and severe depression in a 20-year-old patient
The third patient had been gambling for more than four years, and his family paid off his debts twice. It all began with relatively harmless games, such as live casino and gambling arcade games. As the patient himself admitted, at first he played mainly Plinko and slots. Then a friend shared with him the site ultram dosage for dogs featuring a review of the then-popular game Ice Fishing, and he became interested in live-dealer games. But over time he began to gamble more and more often and place increasingly large bets. He began visiting illegal land-based casinos and underground poker tournaments, where he placed excessively large bets. Several times he tried to quit, but kept returning to gambling. Psychotherapy lasting more than six months did not prevent relapse.
On admission, HAM-D was 27, indicating severe depression. He was prescribed fluoxetine 40 mg/day with an increased risperidone dose — 1.5 mg at bedtime. By discharge: SCL-90 — 118, HAM-A — 8, HAM-D — 11, PSQI — 8. Over 16 months after discharge, gambling behavior did not resume, and depressive symptoms continued to decrease.
Three young men, one regimen
All patients were men aged 20–27 years, with an addiction duration of three to six years, significant social impairment, and an unsuccessful prior experience of psychotherapy. The course of inpatient treatment in each case was 22–23 days, and follow-up lasted from 16 to 22 months without relapse.
Rationale for drug selection
In DSM-5, gambling disorder is classified under addictive disorders. The literature mentions different pharmacological approaches: SSRIs, opioid receptor antagonists, antipsychotics, and mood stabilizers. However, findings are mixed. The authors justified their choice of fluoxetine by its long half-life and lower risk of discontinuation syndrome, and risperidone by its availability and cost-effectiveness.
What may have contributed beyond medication
All patients received CBT and rTMS concurrently. Evidence on transcranial stimulation in this area is conflicting: some studies report symptom reductions within 2–3 weeks, while others suggest that at least 4–6 weeks of daily sessions are needed. It is not possible to disentangle the contribution of each component to the improvement in the described case series.
Why these results should be interpreted with caution
The limitations are obvious and substantial:
• only three patients;
• retrospective design;
• no control groups;
• the concurrent use of three approaches makes it impossible to attribute the effect specifically to the fluoxetine–risperidone combination.
The authors explicitly state that to draw firm conclusions, a multicenter randomized controlled trial with separate arms isolating each intervention is needed. For now, the combination is considered only as a potential option requiring confirmation. All patients provided informed consent, and additional case data may be provided upon request from the publication’s authors.