| Summary: | The gabapentinoids, gabapentin, and pregabalin, target the α2δ subunits of voltage-gated calcium channels. Initially licensed for
pain and seizures, they have become widely prescribed drugs. Many of these uses are off-label for psychiatric indications, and there
is increasing concern about their safety, so it is particularly important to have good evidence to justify this usage. We conducted a
systematic review and meta-analysis of the evidence for three of their common psychiatric uses: bipolar disorder, anxiety, and
insomnia. Fifty-five double-blind randomised controlled trials (RCTs) and 15 open-label studies were identified. For bipolar disorder,
four double-blind RCTs investigating gabapentin, and no double-blind RCTs investigating pregabalin, were identified. A
quantitative synthesis could not be performed due to heterogeneity in the study population, design and outcome measures. Across
the anxiety spectrum, a consistent but not universal effect in favour of gabapentinoids compared to placebo was seen
(standardised mean difference [SMD] ranging between -2.25 and -0.25). Notably, pregabalin (SMD -0.55, 95% CI -0.92 to -0.18) and
gabapentin (SMD -0.92, 95% CI -1.32 to -0.52) were more effective than placebo in reducing preoperative anxiety. In insomnia,
results were inconclusive. We conclude that there is moderate evidence of the efficacy of gabapentinoids in anxiety states, but
minimal evidence in bipolar disorder and insomnia and they should be used for these disorders only with strong justification. This
recommendation applies despite the attractive pharmacological and genetic rationale for targeting voltage-gated calcium
channels.
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