Gabapentin as Monotherapy for Anxiety

Evidence-Based First-Line Treatment

The American College of Cardiology is not relevant here, instead, the guideline-recommended approach prioritizes SSRIs and SNRIs as first-line monotherapy, with escitalopram and sertraline being the preferred first-line agents due to their established efficacy, favorable side effect profiles, and lower risk of discontinuation symptoms 1, 2
Venlafaxine (75-225 mg/day) and duloxetine (60-120 mg/day) are effective SNRI alternatives for generalized anxiety disorder 1
Japanese guidelines specifically recommend SSRIs (fluvoxamine, paroxetine, escitalopram) or venlafaxine for social anxiety disorder with weak but consistent evidence (GRADE 2C) 3

Gabapentin/pregabalin can be considered only when first-line treatments are ineffective or not tolerated, particularly for patients with comorbid pain conditions 1

For adult patients with anxiety disorders, start with SSRI monotherapy, such as escitalopram 5-10 mg daily or sertraline 25-50 mg daily, titrating gradually over 1-2 weeks 1, 2
Allow adequate trial duration, with statistically significant improvement beginning at week 2, clinically significant improvement by week 6, and maximal benefit by week 12 1
If inadequate response after 8-12 weeks, switch to a different SSRI or SNRI 1
Consider gabapentin only after multiple SSRI/SNRI trials have failed or are not tolerated, particularly if comorbid pain conditions exist 1

Never use gabapentin as first-line monotherapy when evidence-based treatments (SSRIs/SNRIs) are available and appropriate 1
Combining medication with cognitive behavioral therapy provides superior outcomes compared to either treatment alone 1, 2