Can gabapentin be used to treat anxiety and symptoms of anger and irritability?

Gabapentin for Anxiety, Anger, and Irritability

Gabapentin is not FDA-approved for anxiety, anger, or irritability but may be considered as an off-label treatment option in specific clinical scenarios when first-line treatments have failed or are contraindicated. 1

Efficacy and Evidence

• Gabapentin has been used off-label for anxiety symptoms with some evidence of effectiveness, particularly in breast cancer survivors where it showed significant improvement in anxiety compared to placebo 2
• Limited evidence exists for gabapentin's use in generalized anxiety disorder (GAD), with only case reports rather than randomized controlled trials 3
• Gabapentin may help with symptoms of irritability and anger as part of its overall calming effect, though this is not well-studied as a primary indication 4

First-Line Treatment Options for Anxiety

• SSRIs and SNRIs are recommended as first-line pharmacological treatments for anxiety disorders with substantial evidence supporting their efficacy 5
• Cognitive behavioral therapy (CBT) is recommended as a first-line non-pharmacological treatment for anxiety disorders 5
• Benzodiazepines may be used for short-term management of severe anxiety but carry risks of dependence and are not recommended for long-term use 6

Safety Concerns with Gabapentin

• FDA labeling warns of serious side effects including:

  • Increased risk of suicidal thoughts and behaviors (approximately one additional case per 530 patients treated) 1
  • Neuropsychiatric adverse reactions, particularly in pediatric patients (3-12 years) including emotional lability, hostility, and thought disorders 1
  • Risk of physical dependence and withdrawal symptoms if stopped abruptly 1

• Gabapentinoids (including gabapentin) have been associated with:

  • Tolerance, dependence, addiction, and withdrawal issues similar to benzodiazepines 7
  • Classification as controlled substances (Class C) in some countries due to abuse potential 7
  • Potential for misuse, though generally considered safer than many other psychotropic medications 8

Appropriate Clinical Use

• Consider gabapentin for anxiety when:

  • First-line treatments (SSRIs, SNRIs, CBT) have failed or are contraindicated 5
  • The patient has comorbid conditions that might benefit from gabapentin (such as neuropathic pain, seizures, or insomnia) 6, 8
  • The patient has a history of substance use disorder and requires an alternative to benzodiazepines 2, 8

• Dosing considerations:

  • Start at lower doses (300 mg daily) and titrate gradually based on response and tolerability 2
  • Higher doses (900 mg daily) may be needed for patients with more severe anxiety symptoms 2
  • Divided doses are typically used (usually 3 times daily) 1

Monitoring and Follow-up

• Monitor for emergence of suicidal thoughts or behaviors, particularly during initial treatment or dose changes 1
• Assess for neuropsychiatric effects including mood changes, hostility, or thought disturbances 1
• Evaluate treatment response regularly using standardized anxiety measures when possible 6
• Do not stop gabapentin abruptly; taper gradually to avoid withdrawal symptoms 1

Important Precautions

• Long-term efficacy and safety data for gabapentin in anxiety disorders are lacking 7
• Evidence for gabapentin in anxiety comes primarily from short-term studies and case reports 2, 3, 7
• Patients should be informed that this is an off-label use not specifically approved by the FDA 1
• Consider potential drug interactions, especially with other CNS depressants including opioids 1, 7

Conclusion

While gabapentin shows some promise for treating anxiety, anger, and irritability, it should be considered a second or third-line option after established treatments with stronger evidence bases have been tried. The decision to use gabapentin should carefully weigh potential benefits against risks of side effects and dependence.