Is gabapentin (Neurontin) used to treat anxiety?

Is Gabapentin Used for Anxiety?

Gabapentin is not a first-line treatment for anxiety disorders but may be considered as a second-line option when SSRIs, SNRIs, or cognitive behavioral therapy have failed or are contraindicated, particularly for social anxiety disorder. 1

First-Line Treatment Hierarchy

The established treatment algorithm for anxiety disorders prioritizes:

• SSRIs and SNRIs are the recommended first-line pharmacological treatments with substantial evidence supporting their efficacy 2, 1
• Cognitive behavioral therapy (CBT) serves as the primary non-pharmacological intervention 1
• Benzodiazepines may be used only for short-term management of severe anxiety due to dependence risks and are explicitly not recommended for long-term use 2, 1

Gabapentin's Role in Anxiety Treatment

Second-line positioning: Canadian clinical practice guidelines specifically list gabapentin as a second-line drug for social anxiety disorder 1. Consider gabapentin when first-line treatments have failed or are contraindicated 1.

Clinical scenarios favoring gabapentin use:

• Patients with comorbid conditions that benefit from gabapentin, including neuropathic pain, seizures, or insomnia 1
• Patients reluctant to take controlled substances like benzodiazepines 3
• Patients with a history of substance use who need to avoid addiction risk 3
• Breast cancer survivors experiencing both anxiety and hot flashes, where gabapentin addresses both symptoms 3

Evidence Quality and Dosing

Research findings show mixed results:

• In breast cancer survivors, gabapentin 300-900 mg demonstrated significant anxiolytic effects at 4 and 8 weeks compared to placebo, with the 300 mg dose showing best outcomes for most patients 3
• For panic disorder, gabapentin showed no overall benefit in the general population but demonstrated significant improvement in more severely ill patients (Panic and Agoraphobia Scale score ≥20) 4
• Preoperative anxiety studies found gabapentin 1,200 mg reduced anxiety scores and pain catastrophizing in highly anxious patients 5
• Simulated public speaking studies showed gabapentin 800 mg attenuated anxiety 6

Critical limitation: No randomized controlled trials exist specifically for generalized anxiety disorder, with only case reports available 7.

Important Caveats and Monitoring

Dependence and withdrawal concerns: Gabapentin carries risks of dependence and withdrawal symptoms with long-term use, particularly when prescribed continuously for 12+ months 2. Patients on long-term gabapentin should be offered careful tapering and support if discontinuation is planned 2.

Sedation profile: Gabapentin causes significant sedation, which may be problematic in ambulatory settings and could delay postoperative discharge 5. When used perioperatively, dosing should be limited to a single lowest preoperative dose to avoid excessive sedative side effects 2.

Dangerous drug interactions: When gabapentin is taken with opioids, dangerous respiratory depression can occur 2. This synergistic effect requires heightened caution in patients on concurrent opioid therapy.

Dose-response relationship: Clinical observations demonstrate a clear dose-response pattern, with lower doses (300 mg) often sufficient for most patients except those with highest baseline anxiety 3, 7.

Practical Implementation

Evaluate treatment response regularly using standardized anxiety measures when possible 1. Monitor for sedation, dizziness, visual disturbances, and peripheral edema 2. Adjust dosing in elderly patients and those with renal dysfunction 2.