The dangers of propranolol for anxiety

In November 2024, a coroner in Blackpool gave a stark warning about the risks of prescribing propranolol for anxiety after a young women died from an overdose.

In a report on the death of 17-year-old Imogen Heap, who had been prescribed the beta-blocker after being diagnosed with anxiety and depression, coroner Alan Wilson outlined that more needs to be done to raise awareness of the toxicity of the drug in overdose^​1​.

Heap had taken a high quantity of propranolol with a view to ending her life before later calling an ambulance. After a delay in the arrival of emergency services owing to NHS pressures, and further delays when she reached the hospital, Heap was placed on life support, later going into cardiac arrest.

In a prevention of future deaths report sent to the National Institute for Health and Clinical Excellence (NICE), Wilson called for updated guidance around the use of propranolol for treating anxiety “with particular reference” to its toxicity in overdose^​1​.

This was not the first time a coroner had raised an issue with propanolol. A similar warning was given in April 2024 after the death of 19-year-old Joshua Delaney in London, who had a history of mental illness and suicidal ideation.

In that case, a GP gave evidence that neither he nor his colleagues had been aware that propranolol carried any significant risk of death through deliberate overdose and had since changed their approach to prescribing^​2​.

There were a further four coroners’ reports raising concerns about propranolol and overdose in 2023, including two in young women aged 19 years and 22 years.

Despite these repeated warnings from coroners, pharmacists and GPs have told The Pharmaceutical Journal that not enough is being done to prevent avoidable harm from the use of a drug that is not even recommended to treat anxiety.

Child and adolescent mental health service (CAMHS) pharmacists, in particular, have stressed that the medicine has “no place” in the treatment of anxiety in young people.

Yet, a paper published in 2022 that looked at general practice data reported increasing prescribing of beta-blockers as anxiolytics between 2003 and 2018 — a trend that was particularly notable in young adults aged under 25 years^​3​.

This is supported by figures obtained by The Pharmaceutical Journal, which show NHS prescribing of propranolol in England has been increasing in young people, and particularly so in the past few years.

The data, requested under the Freedom of Information Act from the NHS Business Services Authority, reveal that 59,717 young people aged 15–19 years were prescribed propranolol in 2023, an increase of 44% from 41,343 young people in 2016.

In those aged 20–24 years, the number increased from 65,610 young people in 2016 to 97,362 young people in 2023, a rise of 48% (see figure).

Although these figures do not show why propranolol is being prescribed to these patients, other common indications for its use — such as hypertension, angina and prophylaxis after myocardial infarction — are more likely to be found in older adults.

Toxic effects

Propranolol is a non-selective beta-adrenergic antagonist, initially developed in the 1960s for angina^​4​. Its use for anxiety began in 1965, when it showed an anxiolytic effect during clinical trials for the treatment of tachycardia in hyperthyroidism.

Although most commonly known for its use in hypertension and angina, it does also have a licence for the treatment of anxiety symptoms, such as palpitations, sweating and tremor, as well as migraine, essential tremor and thyrotoxicosis.

However, it is not recommended by the National Institute for Health and Care Excellence for generalised anxiety disorder and panic disorder in adults^​5​. When drug treatment is needed — as psychological therapy should be the first step — the recommendation is to offer a selective serotonin reuptake inhibitor (SSRI) or a serotonin–noradrenaline reuptake inhibitor (SNRI).

The British Association for Psychopharmacology says propanolol is neither safe nor effective for anxiety disorders, stating in an article: “There is no evidence it is effective (with the possible exception for children with autism spectrum disorder and anxiety) — it has significant side effects and it can be dangerous in overdose.^​6​”

Propranolol is often seen as a relatively safe drug but fatalities have been reported with doses as low as 2,000mg — only 17 days of medicine if prescribed at the highest dose recommended in the British National Formulary (BNF)^​4​.

The toxic effects relate to the blocking of catecholamines at beta 1 and 2 adrenergic receptors, which can trigger a cascade of cardiac complications leading to death.

In 2022/2023, the National Poisons Information Service reported that 318 patients aged 12–86 years deliberately overdosed on propranolol during that year, resulting in 12 deaths^​7​.

Of those cases, 173 involved prescribed propranolol, with 62% of prescriptions given for anxiety management.

It was seeing the risks of overdose first hand in her hospital that prompted Siobhan Gee, consultant pharmacist for psychiatric liaison at South London and the Maudsley NHS Foundation Trust, to look at the issue in more detail.

“In our teams, we had seen a couple of overdoses on propranolol, and I am also chair of an international network of pharmacists who work in liaison settings, and others had noticed the same thing,” she explains.

Gee collaborated with GP and psychiatry colleagues to write an analysis of propranolol in anxiety, published in 2024, which concluded that, “given increasing prescriptions, lack of evidence and significant rates of overdoses, there needs to be greater awareness of the risks when prescribing propranolol”, especially for young people and women, which are not groups that are more generally considered at high risk of suicide.

Missed message

Recent coroners’ warnings were preceded by a report from the Health Services Safety Investigations Body (HSSIB) in 2020^​8​.

The HSSIB pointed to a 33% increase in the number of deaths reported as being linked to propranolol overdose between 2012 and 2017, with 52 deaths recorded as being linked to propranolol overdose in 2017 alone.

The investigation centred around the case of a young woman called Emma who had been diagnosed with anxiety aged 11 years.

Years later, she was prescribed propranolol for migraine by her GP but at the same time was taking citalopram for symptoms of depression and anxiety. She took an overdose and was taken to hospital but died the same day.

The investigation concluded there is a “specific group of patients who may be at an increased risk of using propranolol for self-harm because they have co-existing migraine, depression or anxiety”.

Yet current prescribing guidance “does not contain sufficient warnings” about the severe toxicity of the drug in overdose.

Lack of awareness of the potential for overdose also “hinders the ability of prescribers to exercise clinical judgement”.

The report also found a lack of research on how propranolol may interact with antidepressant medicines when taken in overdose.

Gee says the HSSIB warning should have been more widely reported but its “unfortunate timing” in February 2020 at the start of the COVID-19 pandemic meant the message was missed.

“There’s very little evidence for use of propranolol [for anxiety]. The trials, when you go and dig them out, are very old. They’re all very small. They’re underpowered. They’re not the high-quality trials that you would expect nowadays. And they are in panic disorder and in social phobia not generalised anxiety disorder,” Gee says.

You could make the case that it alleviates some of the symptoms of anxiety, but it is not a treatment for the condition, she adds.

“However, it is still being prescribed, and seemingly in increasing numbers. My hypothesis, and it is only a hypothesis, is that it may partly be because we are trying to discourage the prescribing of [alternatives, such as] benzodiazepines, and also the fact that pregabalin [which is also indicated for anxiety] is now a controlled drug, and so restrictions have increased.”

She says this puts GPs in a tricky position. “If you can’t get access to talking therapy… if the patient has already tried an antidepressant, or doesn’t want one, then you become a bit stuck.”

Yet there does appear to be “misplaced confidence in its safety” that needs to be addressed, she concludes.

Lack of options

Charlotte Archer, a GP and researcher at the University of Bristol, has recently conducted a systematic review on the evidence for beta-blockers in treating anxiety disorders^​9​.

Her paper, published in the Journal of Affective Disorders in January 2025, also found no “robust evidence of effectiveness”.

However, she too is sympathetic to the difficult position GPs can find themselves in.

There is a need to understand both when and why practitioners are using these drugs, and for a large randomised controlled trial to “provide definitive evidence of whether beta-blockers are an effective and safe treatment for anxiety”, she says.

Archer has conducted in-depth interviews with GPs in and around Bristol, which highlight that many view beta-blockers as low-risk, particularly in young adults, and some see them as an alternative to dependence-forming benzodiazepines^​10​.

In 17 interviews, she also heard that GPs found some patients appeared more willing to try beta-blockers than antidepressants, because they did not view them as “mental health drugs” and so found them more acceptable and less stigmatising.

“There’s a lack of treatment options available in primary care settings for GPs to offer patients with anxiety,” she says.

“You’ve got talking therapies, but we know there’s a substantial wait for people to access therapy that way. Antidepressants are commonly given, and they can help, but some patients don’t want to take them. Some practices now have a blanket ban and won’t prescribe any benzodiazepines, and others will only prescribe in really severe, chronic cases.”

Archer adds: “When you take all of those factors into account, it doesn’t leave GPs with many options. Beta-blockers are licensed in the BNF for anxiety, although they’re not NICE-recommended. From a pragmatic point of view, that’s probably why we’re seeing some of this increase.”

National guidance

Rachel Hogan, consultant pharmacist in child and adolescent mental health at Oxford Health NHS Foundation Trust, says that, although there are “pockets of work in lots of different parts of the country”, it needs to be “much clearer from higher up. It needs national guidance and directive.”

The Medicines and Healthcare Regulatory Agency (MHRA) told The Pharmaceutical Journal that it last reviewed propranolol in August 2024 as part of ongoing reviews of all medicines, the outcome of which was to maintain current safety advice and monitoring.

There are no current plans to launch a specific review on the safety of propranolol for use in treating anxiety, the MHRA confirmed.

Alison Cave, MHRA chief safety officer, said in a statement: “Patient safety is our highest priority. The benefits of propranolol continue to outweigh the risks when used at approved doses for licensed indications, including anxiety. 

“The MHRA does — and will continue to — monitor the risks and benefits of medicines that contain propranolol. Any new information, including from Yellow Card reports, will be reviewed, and action taken as necessary if the balance of risk and benefit changes.”

Raising awareness

Archer believes there is “definitely space to increase awareness” of the risks of propranolol in overdose, as well as a need for guidance around the dose and duration of prescribing.

Primary care network (PCN) pharmacist Freyja Powell is one of those trying to raise awareness, prompted by several local incidents involving overdose in young people being treated for anxiety.

She conducted an audit in 2024 of propranolol prescribing in children with anxiety, migraine or other psychological conditions within the three GP surgeries that make up Bath Independent Practices PCN.

The audit revealed that, of 20 patients aged 13–17 years who were prescribed propranolol for anxiety, most had not been checked for risk of overdose. Yet Powell’s analysis suggested more than half of them were at risk owing to self-harm and suicidal ideation.

“It was just being prescribed out of nowhere, no guidelines recommend it in children, and no one was being checked for overdose risk,” she says.

As a result, she ran some education sessions in the practices. The local CAMHS team also set up a direct line for GPs to call for advice on treatment options for specific patients, which Powell says was welcomed by the practices.

“I do feel very passionately that we need to spread the word about this risk.”

Gee agrees and adds that an alert that pops up on GP computer systems when prescribing propranolol would be a simple way to improve awareness.

“Prescribers need to be aware that propranolol is not a safe drug, particularly in overdose. And if we are going to be prescribing it, you should consider why? What are the symptoms that you expect to change? Because that’s how you measure whether or not something’s worked,” he says.

There should also be a “systematic and regular assessment of suicidality” and a limit on the amount prescribed, she adds (see Box).

Gee also points out that improving safety around propranolol is a team effort and says that community pharmacists who are dispensing repeat prescriptions for it have a role to play in checking with the patient how they are taking it and whether it is working.

A pop-up alert for prescribers is something that is in the pipeline within Bath, North East Somerset and Swindon and Wiltshire Integrated Care Board (ICB).

Hogan, who has been working with colleagues, including Powell, to raise awareness across the ICB, says an alert for GP systems in the area to flag the risks and link to advice is being developed. She adds that there are also local guidelines in development, specifically for treating anxiety in under 18-year-olds, which will provide GPs with more support.

“It is about raising awareness, but also looking at what are the alternatives? For young people, it’s got no place in the management of anxiety,” she says.