Gabapentin for anxiety: What you should know about using it off-label

What is gabapentin?

Gabapentin (Neurontin) is an anticonvulsant FDA approved for postherpetic neuralgia (nerve pain that lingers after shingles) and partial seizures, when used alongside other seizure medications.

It is not FDA approved for anxiety, depression, or any other mental health condition, but it’s sometimes prescribed off-label for those uses. In fact, National Ambulatory Care Medical Survey data from 2011-2016 suggests that less than 1% of outpatient prescriptions for gabapentin were for an FDA-approved use, while depression and anxiety were among the most frequent off-label uses.

That said, it doesn’t replace first-choice treatments like antidepressants. “Most patients are looking for first-line medications such as SSRIs and SNRIs. Gabapentin tends to be used adjunctively once those options have been tried.” says Kate Hanselman, PMHNP, VP of Clinical Psychiatry at Thriveworks.

How does gabapentin work for anxiety?

Gabapentin doesn’t work like the medications most people associate with anxiety treatment. It was designed to calm overactive electrical activity in the brain, not to directly target the chemical pathways involved in anxiety disorders.

Despite its name, gabapentin doesn’t directly work on GABA receptors, although it does increase GABA levels. Gabapentin binds to calcium channels in the brain, which is thought to inhibit the release of excitatory neurotransmitters, like glutamate. These neurotransmitters are involved in nerve signaling, pain perception, and, in theory, the kind of overactive arousal that shows up in some forms of anxiety.

This is different from how the more established anxiety treatments work:

• SSRIs (like Zoloft or Lexapro) increase the availability of serotonin in the brain, which can take weeks to produce a noticeable effect but tends to address the persistent worry and rumination common in generalized anxiety.
• SNRIs (like Effexor or Cymbalta) increase the availability of both serotonin and norepinephrine, and like SSRIs they take a few weeks to build effect.
• Benzodiazepines (like Xanax or Ativan) act directly on GABA receptors, producing fast, strong calming effects. But they come with a higher risk for dependence and tolerance over time.

How does gabapentin compare to other anxiety treatments?

SSRIs and SNRIs are considered first-choice treatments for most anxiety disorders. They have decades of large clinical trials behind them, and for generalized anxiety disorder, panic disorder, and social anxiety disorder, that evidence is strong.

Gabapentin doesn’t have that same evidence base. The research that does exist is mixed, but in some cases encouraging.

One of the most-cited studies is a 1999 placebo-controlled trial of 69 adults with social phobia (now called social anxiety disorder). Participants took either gabapentin or a placebo for 14 weeks. The gabapentin group experienced improvements in social phobia symptoms compared to placebo, with no serious adverse events reported. The most common side effects, like dizziness, dry mouth, drowsiness, nausea, and decreased libido, occurred more often in the gabapentin group.

For generalized anxiety disorder (GAD), the picture is thinner. While a 2017 case report shows that gabapentin was a helpful alternative to benzodiazepines in one patient, currently no randomized controlled trials exist for gabapentin in GAD specifically. For panic disorder, a placebo-controlled trial found no overall difference between gabapentin and placebo, though it did show some benefit in patients with more severe symptoms at the start.

Given this, gabapentin tends to come up in a few specific situations rather than as a default option:

• When SSRIs or SNRIs haven’t worked or caused bothersome side effects.
• When anxiety overlaps with another condition gabapentin can also help with, such as certain types of chronic pain, alcohol use disorder, or insomnia.
• When a provider wants to avoid benzodiazepines. Gabapentin doesn’t carry the same risk for physical dependence for most people, which sometimes makes it an alternative for short-term symptom relief.
• As an add-on, not a replacement. Some providers use gabapentin alongside an existing antidepressant rather than instead of one, particularly when physical symptoms like muscle tension or sleep disruption are prominent.

“Gabapentin may be an option if someone hasn’t responded to first-choice, FDA-approved treatments, or if they have partially responded but need additional treatment,” Hanselman says.

What are the risks and side effects?

“When prescribed appropriately, gabapentin doesn’t usually cause noticeable side effects. It’s usually well-tolerated,” Hanselman says. That said, if you’re experiencing troublesome side effects it’s always worth checking in with your provider.

The most frequently reported side effects in clinical trials include:

• Drowsiness and fatigue
• Dizziness
• Lack of coordination (ataxia)
• Nausea or vomiting
• Blurred or double vision
• Swelling, usually in the legs or feet
• Dry mouth
• Tremor

These effects tend to be more common when first starting gabapentin or after a dosage increase, and often improve as the body adjusts.

Who shouldn’t take gabapentin?

“The most important things I confirm before prescribing is that the person isn’t allergic to gabapentin, isn’t taking medications that could interact with it or increase sedative effects, doesn’t have underlying medical issues that make it inappropriate, and hasn’t had a poor response or bothersome side effects with it in the past,” Hanselman says.

Gabapentin may not be recommended for:

• People with kidney problems. Your body gets rid of gabapentin almost entirely through the kidneys, so if you have kidney problems you may need a lower dose.
• People taking opioids or other sedatives. In December 2019, the FDA issued a safety warning about serious, sometimes fatal breathing problems linked to gabapentin, particularly when combined with opioids or other central nervous system depressants like alcohol or benzodiazepines. Older adults and people with conditions like COPD that already affect lung function are at a higher risk.
• People with a history of substance use disorder. Gabapentin carries some potential for misuse (covered in more detail below). That risk may be higher for those with a prior history of substance use.
• People who are pregnant or breastfeeding. Animal studies have shown developmental risks at doses similar to those used in humans, and gabapentin passes into breast milk. This is a conversation to have directly with your provider.

It’s also worth knowing that, like other anticonvulsants, gabapentin carries an FDA-required warning about a small increased risk of suicidal thoughts or behavior. That said, researchers note that the warning is based on an analysis that lumped together various anticonvulsants that work very differently

The question isn’t fully settled, but the practical takeaway doesn’t change much either way: Anyone taking gabapentin should be monitored for new or worsening depression, anxiety, agitation, or unusual changes in mood, and should reach out to their provider right away if these come up.

If you or someone you know is having thoughts of suicide, the 988 Suicide & Crisis Lifeline (call or text 988) is available 24/7.

Is gabapentin addictive?

For most people taking it as prescribed, gabapentin has a low risk of addiction. But “low” isn’t “none,” and the picture depends a lot on who’s taking it.

The clearest risk shows up in people with a history of opioid use disorder or other substance use, where gabapentin may be used to amplify the euphoric effects of opioids or to self-treat withdrawal. There are a number of states that have started classifying gabapentin as a controlled substance or tracking it through prescription monitoring programs, even though it isn’t a controlled substance federally.

Gabapentin may also lead to physical dependence. So stopping abruptly can cause withdrawal symptoms like anxiety, insomnia, nausea, and sweating, which is why providers usually taper the dose gradually rather than discontinuing all at once.

“Any risk of misuse is something we assess for and manage together, with a shared focus on helping the patient feel better as safely and effectively as possible,” Hanselman says.

When to talk to a provider about gabapentin, and what to ask

You might bring up gabapentin if you’ve tried one or more FDA-approved anxiety treatments without much relief, if side effects from those medications haven’t been manageable, or if your anxiety symptoms overlap with other health concerns that gabapentin may be used for (off-label or otherwise).

Here are some questions worth asking your provider:

• Could gabapentin help with my situation specifically, given my history and symptoms?
• What’s a realistic timeline for noticing a difference?
• What dose will I start at, and how will it be adjusted?
• Do any of my other medications or health conditions impact my risk of side effects or adverse events when using gabapentin?
• What’s the plan if this doesn’t help, or if side effects are difficult to manage?

“Completing a full trial of first-choice treatment, at the maximum tolerated dose for at least eight to 12 weeks, is essential before exploring additional options,” Hanselman says. “Many people haven’t actually completed a full trial of even one medication before considering something else.”

Making an informed decision

Gabapentin isn’t a frontline anxiety treatment, and there is far less research on it than what exists for SSRIs, SNRIs, or therapy. But for specific situations, like treatment resistance, co-occurring conditions, or a need to avoid benzodiazepines, it’s a legitimate option some providers turn to.

If your provider has brought it up, that doesn’t mean something’s wrong or that you’re out of standard options. It’s worth an open conversation about why this medication, for your specific situation, makes sense.

Frequently asked questions (FAQs)

Does gabapentin help with anxiety?

It may help for some people, particularly those with social anxiety disorder. Evidence for generalized anxiety disorder is limited and consists mostly of case reports.

Is gabapentin FDA-approved for anxiety?

No. Gabapentin is FDA approved only for postherpetic neuralgia and as an add-on treatment for partial seizures.

What is gabapentin usually prescribed for?

Most gabapentin prescriptions are for off-label uses, including nerve pain conditions like diabetic neuropathy, anxiety, alcohol withdrawal, and insomnia. Its only FDA-approved uses are postherpetic neuralgia and partial seizures.

How long does gabapentin take to work for anxiety?

There’s no officially established timeline since it isn’t an approved use, but in the studies that do exist, effects on anxiety symptoms were generally measured over several weeks of consistent dosing.

Is gabapentin addictive?

Gabapentin isn’t a federally controlled substance and has a lower misuse risk than benzodiazepines or opioids. But it does carry some potential for misuse, particularly in people with a history of substance use disorder, and stopping it abruptly can cause withdrawal symptoms.

Is gabapentin better than benzodiazepines for anxiety?

“Better” is different for each person. Benzodiazepines tend to work faster for acute anxiety but carry a higher risk for dependence and tolerance with regular use. Gabapentin works more gradually and has different risks. There is also less evidence for its efficacy in treating anxiety.

Can I take gabapentin with antidepressants?

Gabapentin and antidepressants are sometimes prescribed together, but this should always be guided by your provider, who can account for your specific medications, dosages, and any potential interactions.

Who should not take gabapentin?

Anyone with a known allergy to gabapentin shouldn’t take it. People with kidney problems, a history of substance use disorder, or those taking opioids or other sedating medications need closer monitoring and may require dosage adjustments. Pregnant or breastfeeding individuals should discuss the risks and benefits directly with their provider.