Gabapentin is a relatively safe adjunct, not a mood stabilizer: in bipolar disorder it supports sleep and anxiety while a real mood stabilizer does the work. For sleep it helps a little, so we save it for when there are comorbidities, and for anxiety it only works at doses far above the 100 or 300 mg people are usually on.
When we reach for it
For sleep, gabapentin always just helps a little; we have never had the really appreciative patient. We tend to reserve it for when there are comorbidities.
“Gabapentin always just helps a little bit. I've never had that really appreciative patient who's like, oh, you really helped me out, doc. So I agree. I tend to reserve it for when there's comorbidities”
56:38Sleep Medications Treatment Tier List: Best Insomnia Medications RankedAug 2026 For sleep, give a medication, usually trazodone or gabapentin. Hydroxyzine is fine too. Avoid anticholinergics like Benadryl if you can.
“I give some kind of a medication. It's usually trazodone or gabapentin. Hydroxyzine is just fine, too. I avoid anticholinergics like Benadryl, if I can help it”
11:41PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22Apr 2025 We do not do the classic benzodiazepine bridge for the first weeks of an SSRI. If a patient truly needs a PRN, we still encourage against it, but we use gabapentin or hydroxyzine.
“So yes, I don't do the classical thing of benzos with the first couple weeks of the SRI. I don't do that. If they want a PRN, they need a PRN for some reason, I still encourage against it. I'm not going to not use it if the clinical situation is right for it. I'll use gabapentin or hydroxyzine”
22:05Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 Mood stabilizers have not been terribly helpful. Only the non-traditional ones, Topamax and gabapentin, are more usable.
“They've talked about using mood stabilizers. I have not found that to be terribly helpful. Only the non-traditional mood stabilizers, not really mood stabilizers, Topamax and Gabapentin, I think, are more usable”
19:29PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22Apr 2025 If akathisia is more like a mild restless-legs feeling that only comes at night, nighttime gabapentin can be quite effective.
“Long term, I do prefer to put people on propranolol. twice a day. You can get effect from as little as 10 milligrams twice a day for akathisia. If the akathisia is more like a restless legs thing that's mild and only at night, gabapentin can be quite effective, nighttime gabapentin”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025
In bipolar disorder
It is not a mood stabilizer. The evidence is not there for primary mood stabilization, and on its own it just doesn't really work. Think of it as an adjunct: relatively safe, apart from a small risk of withdrawal and tolerance.
“They tried it out, but it's just a relatively safe choice, you know. Except for the small amount of withdrawal and tolerance possibility. Think of it as an adjunct in the same category, but certainly not a solo medication. It just doesn't really work”
7:40Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026 Also said in 1 more episode
“Gabapentin, the evidence is not there as a primary mood stabilization agent. Don't think about it that way. But I encourage you to think about it as an adjunctive treatment in bipolar disorders”
23:54The Best Bipolar Medication Review From The Best Bipolar ExpertJan 2025 As an adjunct, it is a nice sleep and anxiety support while you truly treat with a mood stabilizer. In bipolar disorder we are much more likely to reach for it for sleep, though it is only ever adjunctive, for things like anxiety and insomnia.
“But is it really efficacious for true bipolarity? Not really, but I think it's a nice option as a sleep support medication and anxiety support medication in the context of trying to truly treat with a mood stabilizer”
59:01Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026 Also said in 2 more episodes
“I'm much more likely to reach for Gabapentin. And some of you may know that Gabapentin enjoyed more enthusiasm earlier in... the 2000s, as an agent for bipolar disorders”
44:23Insomnia and Sleep Medications in PsychiatryDec 2024 “It's always at best a adjunctive treatment. Right. And it's adjunctive treatment only for things like anxiety and insomnia. in the bipolar disorder. It's not the primary treatment”
45:47Insomnia and Sleep Medications in PsychiatryDec 2024 One first-line combination for acute mania is lithium, lurasidone and gabapentin: lurasidone works quickly at low doses, and lithium is the most effective long term.
“It's lithium. Okay. And... It's latuda, and then it's gabapentin. And why? Because I find latuda to be effective quickly and at low doses. Lithium is most effective long-term”
44:48The Best Bipolar Medication Review From The Best Bipolar ExpertJan 2025
Dosing
For anxiety, the studies needed much higher doses than the 100 or 300 mg people are usually on. It is more effective at about 900 to 3,600 mg a day, and because absorption is nonlinear, much less is absorbed at the higher doses than the number suggests.
“studies needed much higher doses than what I see it be used at to show an effect on anxiety. I feel like all the time you see people on 100 milligrams, 300 milligrams of Gabapack”
54:29Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 Also said in 1 more episode
“Typically, it's more effective at the like 900 to 3,600 milligrams per day range. And It's important to remember that gabapentin has, quote unquote, nonlinear pharmacokinetics, which is just a fancy way of saying that like, you know, 2400 sounds like a mega dose, but significantly less is absorbed as you get to the higher doses”
24:54Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 Cap a single dose at about 1,200 mg and split anything more into a separate dose. We do not give a lot of gabapentin for anxiety disorders, but we are not opposed to it.
“I try to cap it at 1,200 personally. I feel like, what are you doing at that point? Just separate it out into a different dose. Do I give a lot of gabapentin for anxiety disorder? No, but I'm not opposed to it”
25:51Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 A simple start: 300 mg, go to 600 if it is not enough and call; if it is way too much, call and switch to 100s. Titrate to effect.
“I'll start with 300 and I'll say, if it's not enough, go to 600 and call me. And if it's way too much, call me and I'll send you 100s. So basically starting on 300 and then titrating to effect”
1:05:32Insomnia and Sleep Medications in PsychiatryDec 2024
Side effects and safety
At high doses you are getting into broad suppression of neurons, so habituation is possible, though we have not seen it in our patients.
“We have to understand that we're starting to get into the territory of just broad suppression of neurons and that there could be habituation. I've never seen it with my patients on gabapentin”
26:06Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025
Compared with others
Pregabalin has more evidence in anxiety. Gabapentin is usually thought of as a little more tolerable, with less abuse risk.
“So it does have more evidence in anxiety. Typically how it's thought of is gabapentin might be a little bit more tolerable and less abuse risk”
27:24Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025
Earlier we said
Older episodes that put it differently. The points above are the newer view.
We used to name gabapentin, with trazodone, as a first-line, non-habit-forming sleeper from day one of depression treatment, and as one of the broadly applicable sleep medications in most disorders, with hydroxyzine.
“on day one, I will give sleepers. And by that, I mean the non-habit-forming ones that are more likely to support deep, healthy sleep, trazodone, gabapentin, are my first lines for that. If you can't tolerate or have to take something else for some reason, hydroxyzine is a fair choice too”
36:32Treating Depression: Practical Tips & Pearls for Anti-Depressant MedicationsJan 2025 Also said in 1 more episode
“The broadly applicable medications for sleep in most to all disorders are therefore hydroxyzine, trazodone, and gabapentin. And melatonin is a runner-up because it's not regulated and it kind of depends on which one you buy”
28:18Insomnia and Sleep Medications in PsychiatryDec 2024
It also comes up on
- AnxietyThe usual order: an SSRI, then another SSRI, then augmenting with buspirone or gabapentin. If they are still unresponsive, go by patient characteristics, such as mirtazapine for a lot of sleep trouble.
- AugmentationFor anxiety: if one SSRI fails, switch to another, then consider buspirone or gabapentin as augmenting agents. If the patient is still unresponsive, start choosing by patient characteristics, such as mirtazapine when sleep is a big problem.
- AnxietyParoxetine is not better for anxiety than the others. Anxious people tend to worsen at night, so anything sleepy helps, and that can be a little gabapentin.
- BenzodiazepinesA short-term sleeper can just as easily be high-dose hydroxyzine, low-dose trazodone, higher-dose gabapentin, or mirtazapine if you have to.
- Borderline personality disorderWhen the picture is likely trauma or personality and the diagnosis is undifferentiated, start with smaller things such as gabapentin, hydroxyzine, buspirone or propranolol, not serotonergic drugs, because of the risk of agitating a bipolar disorder.
- Generalized anxiety disorderMost of what you want from low-dose quetiapine in a non-psychotic disorder can be had with mirtazapine, gabapentin, buspirone or hydroxyzine.
- Generalized anxiety disorderThe traditional algorithm goes SSRI, then SNRI, then gabapentin and pregabalin, then a tricyclic.
- HydroxyzineA short-term sleeper can just as easily be high-dose hydroxyzine, low-dose trazodone, higher-dose gabapentin or, if you have to, mirtazapine.
From these episodes
- Sleep Medications Treatment Tier List: Best Insomnia Medications RankedAug 2026 · 1 point
- Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026 · 2 points
- Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 · 1 point
- Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 · 5 points
- PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22Apr 2025 · 2 points
- Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025 · 1 point
- The Best Bipolar Medication Review From The Best Bipolar ExpertJan 2025 · 2 points
- Insomnia and Sleep Medications in PsychiatryDec 2024 · 3 points
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.