Gabapentin in the Management of Anxiety Disorders – Evidence‑Based Guidance

1. Positioning of Gabapentin in Anxiety Treatment

The Canadian Clinical Practice Guideline lists gabapentin as a second‑line option for social anxiety disorder, positioned below SSRIs, SNRIs, and pregabalin, and it may be used as a third‑line agent when first‑line (e.g., escitalopram, sertraline) and second‑line therapies have failed【1】.
For generalized anxiety disorder (GAD), guideline‑based first‑line pharmacotherapy consists of SSRIs (escitalopram, sertraline, paroxetine, fluvoxamine) and SNRIs (venlafaxine; duloxetine has demonstrated efficacy)【1】【6】.

Dependence and withdrawal: Gabapentinoids, including gabapentin, are associated with tolerance, physical dependence, and withdrawal symptoms comparable to benzodiazepines【2】.
Long‑term prescribing: Approximately 50 % of patients receiving gabapentinoids continue therapy for ≥12 months without clear evidence of sustained benefit, highlighting potential overuse【2】.
Concurrent opioid use markedly increases the risk of respiratory depression and fatal overdose; co‑prescription should be avoided whenever possible【2】.
Common adverse effects are dose‑dependent dizziness and sedation, which may limit tolerability in some patients【4】【5】.

In the United States, gabapentin has been classified as a Schedule V controlled substance because of its abuse potential【3】.

Acute anxiety (e.g., pandemic‑related): Benzodiazepines remain the standard of care; lorazepam 0.5–1 mg PO up to four times daily (max 4 mg/24 h), with dose reduction to 0.25–0.5 mg in older adults【7】.
Insomnia with comorbid anxiety: Short‑acting benzodiazepine‑receptor agonists or ramelteon are recommended over gabapentin【8】.

All statements are derived from peer‑reviewed guideline or clinical evidence and are accompanied by the corresponding citation.