Psychiatrists may prescribe anticonvulsants for people who don’t tolerate or respond to first-line medications, like SSRIs.
Though anxiety disorders are common, the primary treatments may not work for everyone. Anticonvulsants may be used for treatment-resistant anxiety, in some instances, under the supervision of an experienced psychiatrist.
Researchers believe anticonvulsants decrease excitability in the brain, with fewer side effects than alternatives. It’s important to tailor each treatment, whether it’s an anticonvulsant, a combination of medications, or talk therapy.
Also known as antiepileptics, anticonvulsants are primarily intended to treat seizures. When other medications aren’t effective, anticonvulsants may be prescribed as an off-label treatment for anxiety disorders and post-traumatic stress disorders (PTSD).
Beyond antiepileptic properties, anticonvulsants can reduce the physical experience of anxiety, sometimes referred to as somatic anxiety. Anticonvulsants can also support mood regulation by acting on the emotional and behavioral brain.
“Gabapentin is structurally similar to GABA—a neurotransmitter found naturally in the body,” according to Dr. Dana Siperstein, a psychiatrist in Rhode Island. “Simply, GABA decreases brain cell excitability in the nervous system.”
An overexcitement of neurons can influence how we respond to stimuli, which research links to feelings of
- fear
- anxiety
- sleep disturbances
- mood swings
- anger
- impulsiveness
Anticonvulsant medications may be therapeutic because of their ability to limit excessive activation.
Types of anticonvulsants
There are different anticonvulsants, including:
- GABAergic enhancers
- ion channel modulators
- medications that work on both mechanisms
Researchers aim to group anticonvulsants by how they act in the body.
GABAergic medications affect GABA, the primary inhibitory neurotransmitter in the nervous system.
Ion-channel modulators target specific molecules, including calcium or sodium.
GABAergic medications for anxiety include benzodiazepines, as well as pregabalin and gabapentin.
Sodium ion channel medications include:
The anticonvulsants gabapentin and pregabalin are believed to have multiple modes of action, including potential modulation of GABA and the calcium ion channel.
Benzodiazepines work on anxiety by binding to GABA receptor agonists, also known as GABA-A receptors. Because of the high potential for physical dependence, benzodiazepines may be prescribed in the short-term, on an as-needed basis, for severe anxiety and panic disorder.
But a recent study examining medications for anxiety didn’t include all anticonvulsants. Just because an anticonvulsant is GABAergic doesn’t mean physicians will prescribe it to treat anxiety.
For example, the study didn’t mention tiagabine, a GABA reuptake transporter, and vigabatrin, a GABA transaminase inhibitor.
When treating anxiety with medication, physicians might select an antidepressant, anticonvulsant, or antipsychotic. Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), are considered first-line treatments.
Antidepressants remain a mainstay psychopharmacological option for treating anxiety, Dr. Siperstein says.
Most people with anxiety respond to antidepressants, benzodiazepines, therapy, or a combination of approaches. About one-third of individuals experience treatment-resistant anxiety, according to a 2020 study.
“It’s helpful to have alternative options for those who don’t tolerate antidepressants, or when antidepressants aren’t appropriate,” she added. “For example, one anticonvulsant that I find particularly beneficial is gabapentin.”
But that doesn’t mean there’s a one-size-fits-all anticonvulsant for anxiety. Anticonvulsants like gabapentin may be used as a stand-alone or adjunctive therapy, like a secondary treatment intended to enhance the effects of the primary treatment.
Before prescribing medication to treat anxiety symptoms, it’s essential to identify the type of anxiety. The five major anxiety disorders include:
For example, the best anticonvulsant for generalized anxiety may differ from the best anticonvulsant for panic disorder or social anxiety.
Psychiatrists prescribe medication only after comparing the expected benefits and potential side effects, making decisions after carefully considering data, history, and preferences.
“Medication management in psychiatry is equal parts science and art,” Dr. Siperstein says. “I always try to tailor treatment options to individual and specific needs.”
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For both medications, there’s potential for long and short-term effects. The duration of use and dosage can influence the presence and severity of side effects.
“Anticonvulsants and antipsychotics each have many different uses and varied nuances in terms of side effect profiles,” Dr. Siperstein says.
Benzodiazepines may cause sedation, impaired concentration, and memory deficits. When someone is living with depression and anxiety, chronic use of benzodiazepines may reduce the effectiveness of antidepressants.
Research indicates two anticonvulsants—valproate and carbamazepine—can cause congenital defects and developmental issues when taken by pregnant women.
Despite potential effectiveness in treating panic disorder, these medications aren’t prescribed to women who can bear children.
Side effects of antipsychotics may include:
- appetite changes weight gain
- sedation
- fatigue
- insomnia
- jitteriness
- dyspepsia
- nausea
Typical antipsychotics, or first-generation antipsychotics, have been associated with severe adverse effects, such as tardive dyskinesia and metabolic syndrome. Second-generation antipsychotics are associated with metabolic syndrome and weight gain.
Dr. Sheenie Ambardar, an adult psychiatrist in Los Angeles, has frequently prescribed anticonvulsants and antipsychotics to treat anxiety. She states that gabapentin is well tolerated by many patients, treating their anxiety with fewer side effects.
“The improved side effect profile is the main reason I prefer these anticonvulsants,” Dr. Ambardar added. “Although antipsychotics can work well too, in certain cases.”
When using anticonvulsants to treat anxiety, another
Dr. David Culpepper, clinical director at LifeMD, says an individual who takes gabapentin or another anticonvulsant could feel the benefits immediately, making it effective in treating the symptoms of anxiety and panic disorder.
Antipsychotics, in contrast, work on a long-term basis and may not take effect for up to 6 weeks.
Because anticonvulsants act on a short-term basis, there’s a risk of becoming physically dependent. “The risk of dependency on anticonvulsants is relatively mild compared to other anti-anxiety medications, such as benzodiazepines, which have been shown to be highly addictive.”
Though not approved for anxiety in the U.S., the European Medicines Agency approved pregabalin for generalized anxiety. Only one antipsychotic, first-gen trifluoperazine, is FDA-approved for anxiety.
Cognitive behavioral therapy (CBT) may be used to treat anxiety, often in combination with medication. It’s one of many types of therapy for anxiety.
“Psychotherapy is a mainstay of treatment for anxiety,” Dr. Siperstein says, crediting most improvement to a combination of psychotherapy and medication management.
There are also a variety of natural, alternative treatments for anxiety, such as mindfulness, herbal supplements, and exercise.
Additionally, the safety and effectiveness of neuropeptide pathways, glutamate, endocannabinoids, phytochemicals, and hallucinogens for treating anxiety are currently being investigated.
Researchers will continue to evaluate the therapeutic potential of emerging options, which could become adjunctive treatment aids in the future.
An effective, tolerable, and purposeful approach to anxiety is the goal, Dr. Siperstein says. Co-occurring conditions and medication interactions are vital considerations.
“Sometimes medication can be a short-term, time-limited tool to help therapy go better so that patients are able to not feel so ‘stuck,'” Dr. Siperstein says. In other cases, chronic anxiety may benefit from long-term pharmacotherapy.
A psychiatrist will define a trial period, monitor the response to medication, and consistently re-evaluate the benefits. Other forms of therapy in combination with medication management can work together to reduce anxiety.
“There are pros and cons to each option,” Dr. Siperstein says. “It’s important to work with someone with significant experience and knowledge in these more nuanced treatments.”