What do you use for treatment-refractory anxiety where trials of antidepressants have not worked either from ability to tolerate or inadequate effect?

I find gabapentin to be very helpful for anxiety. Other agents I've found helpful include the alpha-2 agonists clonidine and guanfacine, which I've found particularly helpful for people with trauma-related anxiety and anxiety with somatic symptoms. Both are also helpful for nightmares.

Regarding gabapentin, the tricky part is finding the right dose. Some patients can be sensitive to the initial dizziness and sedation, which generally wears off after 1-2 days. I typically give patients a prescription for 100mg TID with instructions to increase by 100mg daily as needed and as tolerated until they find a dose that works for them. I typically have them call me or check in if they reach 300-400mg TID so that we can reassess and typically give t...