What is the preferred treatment between buspirone and gabapentin (Neurontin) for anxiety disorders?

Buspirone vs Gabapentin for Anxiety Disorders

For generalized anxiety disorder, buspirone is the preferred choice as it has established efficacy with FDA approval and guideline support, whereas gabapentin lacks evidence-based support for primary anxiety treatment. 1, 2

Evidence-Based Rationale

Buspirone for Anxiety Disorders

Buspirone is specifically indicated and proven effective for generalized anxiety disorder (GAD). 1, 2, 3

• Well-controlled clinical trials demonstrate buspirone's anxiolytic properties are similar to benzodiazepines and significantly superior to placebo for GAD. 1
• Buspirone is effective as monotherapy and shows particular benefit in patients with chronic anxiety, elderly patients, and those with mixed anxiety-depression symptoms. 1, 4
• The drug lacks dependence potential, withdrawal issues, and sedation compared to benzodiazepines, making it safer for long-term management. 2, 3
• Buspirone does not potentiate alcohol or other sedative-hypnotics and maintains a favorable safety profile even at high doses. 3

Important Limitations of Buspirone

Buspirone is NOT effective for panic disorder or other specific anxiety disorders beyond GAD. 1, 2

• Studies in panic disorder have been inconclusive, and buspirone is not recommended for routine panic disorder treatment. 1
• Evidence for obsessive-compulsive disorder shows only preliminary indications requiring an adjunctive role. 2
• Social phobia studies have not clearly demonstrated buspirone's effectiveness compared to reference standards. 2

Onset and Patient Selection Considerations

Buspirone requires patient counseling about delayed onset of action. 1, 5

• The drug works best in patients who do not demand immediate relief or expect the rapid benzodiazepine-like response. 1
• Onset of action is gradual but equivalent to benzodiazepines when measured over appropriate timeframes. 2
• Long-term use is well-tolerated without habituation or withdrawal problems. 2

Gabapentin for Anxiety

Gabapentin is not included in anxiety disorder treatment guidelines and lacks adequate evidence for primary anxiety treatment. The provided evidence contains no guideline or high-quality research supporting gabapentin for anxiety disorders. While gabapentin may be used off-label in clinical practice, this represents empiric treatment without the evidence base that supports buspirone.

Clinical Algorithm

For a patient presenting with anxiety:

1. Determine the specific anxiety disorder diagnosis - this is critical as buspirone's efficacy is disorder-specific. 2

2. If GAD is confirmed:

   • First-line option: Buspirone 15-60 mg/day for patients who can tolerate 2-4 weeks for full effect. 1, 5
   • Particularly appropriate for elderly patients, those with substance use concerns, or patients requiring long-term treatment. 1, 2

3. If panic disorder, social phobia, or OCD:

   • Do NOT use buspirone as monotherapy - consider SSRIs (paroxetine, sertraline) or venlafaxine instead. 2, 5

4. If comorbid depression exists:

   • Buspirone can be used alone or augmented with antidepressants, as it shows efficacy for depression and mixed anxiety-depression. 1, 4
   • When augmenting citalopram, moderate-quality evidence shows bupropion decreases depression severity more than buspirone, though both are reasonable options. 6

Common Pitfalls to Avoid

• Do not prescribe buspirone expecting immediate anxiety relief - patients must understand the gradual onset to prevent premature discontinuation. 1
• Do not use buspirone for panic attacks - the evidence does not support this indication. 1, 2
• Do not assume all anxiety disorders respond equally - buspirone's efficacy is specific to GAD. 2
• Gabapentin should not be considered equivalent to buspirone - it lacks the evidence base and guideline support for anxiety treatment.