Neurontin as a first line agent . . . I Don't Think So!

I received this question from a concerned consumer last week . . .

A week ago I was prescribed gabapentin, an anti-epileptic drug, for the off-label use of social anxiety and “affective mood disorder.” I have been concerned about this ever since I began my research on it a few days ago. Most of what I have read says that it should remain a second-tier drug until more controlled studies are conducted. While I am not sure if your comments on Trileptal holds true for gabapentin, it seems probable that they would. My concern is because although most of the studies I have read say that gabapentin, and other drugs of its type, are used off-label only when other medications have proved intractable, my psychiatrist prescribed them right off…as a first-line drug. “Front-line experience” is well and good, but it is still anecdotal. I feel rather like I am part of an informal experiment, sort of like a guinnea pig. He also did not inquire at all into my past to see if there were psychological roots to my anxieties. He said we would try the medicine first and then determine if “talking therapy” was needed. Should it not be the other way around? Should we not be trying to avoid medicinal intervention whenever possible? I am of the opinion that I need a second opinion…do you agree? I apologize if I am rambling. I actually did begin the medication and THEN began my research, so I am under the influence of its side-effects. I am at odds with myself as to how best to proceed. Thank you for your patience.

Well . . . not really a guinea pig.  The use of neurontin as a first line agent is not typical for the industry.  Not that neurontin is a big scary drug that will make you spout horns like some of the poisons we use.  More because it doesn’t work that well.  Neurontin is a medicine looking for a cause.  It got caught up in the wave of anti-seizure medicines being used for psychiatric purposes. Medicines like Depakote and Lamictal have earned their stripes and are commonly used and approved by the FDA.  Trileptal has not been approved, but has become a staple in our arsenal of medications because it works well.  Neurontin . . . well . . . it’s kind of that medicine that is used when you don’t know what else to do.  Despite initial claims of efficacy, there is virtually no data showing it can be helpful for psychiatric purposes.  When it is used (and, yes, I have used it this way) it is most often to address anxiety issues such as social anxiety or generalized anxiety AFTER other treatments have failed.  Because it has some efficacy for chronic pain syndromes (such as fibromyalgia), it is sometimes used in that population of patients earlier rather than later.  It is not used as a treatment for “affective mood disorder” . . . whatever that is . . .

My biggest concern is not that the medicine will put you at risk.  Neurontin is an innocuous drug that does not have a significant side effect profile.  Untreated anxiety, however, will put you at risk, as will untreated depression.  I am also concerned that you were told that “talk therapy” was a second line treatment.  It is VERY clear that social anxiety and depression are amenable to intervention with appropriate therapies (cognitive therapy is best), and I personally EXPECT my patients on medicines to be in therapy.  

Sounds like you might need a second opinion.

–Dan Hartman, MD

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