Pregabalin belongs at the end of the list for primary anxiety: once the diagnosis has been revisited and the patient is in real therapy and practicing mindfulness without getting anywhere, do not be afraid to use it. It has more evidence in anxiety than gabapentin, but it is too effective: its absorption makes it possibly habit-forming, with a higher risk of withdrawal.
When we reach for it
When you reach the end of your list for primary anxiety (you have revisited the diagnosis, the patient is in real therapy and practicing mindfulness, and you are still not getting anywhere), do not be afraid to use pregabalin.
“if you're getting to the end of your list for the treatment of primary anxiety, you've done the re-diagnosis, they're in true therapy, they're doing mindfulness practice, and you're not really getting anywhere, Don't be afraid to do pregabalin”
55:53Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 It has more evidence in anxiety than gabapentin. The usual thinking is that gabapentin may be 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 For sleep: when someone has a genuine chronic pain or neuropathic pain reason to take pregabalin, dosing it at night can be a nice synergistic move, since chronic pain causes a lot of problems with sleep.
“if someone, let's say, has a genuine chronic pain, neuropathic pain, reason to be taking pregabalin and you dose it at night, it can be a nice synergistic thing because chronic pain can really cause a lot of problems with sleep, obviously”
56:07Sleep Medications Treatment Tier List: Best Insomnia Medications RankedAug 2026
Side effects and safety
It is too effective: the speed and amount of its absorption are enough to make it possibly habit-forming, which also means a higher risk of withdrawal effects.
“Lyrica is too effective. The absorption, speed, and amount is sufficient to make this a possibly habit-forming drug. And, of course, that also means that the risk of withdrawal effects are higher”
27:45Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025
It also comes up on
- Generalized anxiety disorderThe traditional algorithm goes SSRI, then SNRI, then gabapentin and pregabalin, then a tricyclic.
- ImipramineThe traditional algorithm goes SSRIs, then an SNRI, then gabapentin and pregabalin, and then a tricyclic.
- Tricyclic antidepressantsThe traditional algorithm for GAD runs SSRI, then SNRI, then gabapentin or pregabalin, then a TCA.
From these episodes
- Sleep Medications Treatment Tier List: Best Insomnia Medications RankedAug 2026 · 1 point
- 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 · 2 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.