Propranolol for Anxiety: Independent Evidence, Overdose Risk & Side Effects

Table of contents

• Evidence summary
• What propranolol is
• How it works
• What it is prescribed for
• What works and what does not
• Benefits by claim
• Risks and all side effects
• All interactions
• Who should avoid propranolol
• Dosage and how to take it
• Follow the money: who makes it and who funded the evidence
• Related research
• Frequently asked questions
• Sources and funding notes

Evidence summary

Independent evidence and credibility scorecard

What propranolol is

Propranolol is a non-selective beta blocker. That means it blocks both beta-1 receptors, found mainly in the heart, and beta-2 receptors, found in the lungs, blood vessels and elsewhere (Inderal SmPC).

• Brand names: Inderal in the UK and US. The NHS also lists Bedranol, Beta-Prograne and Half Beta-Prograne (NHS). In the US, the extended-release Inderal LA and InnoPran XL are held by ANI Pharmaceuticals (Drugs@FDA, NDA 018553).
• Originator: propranolol was developed in the UK by James Black and colleagues at ICI, where he worked from 1958 to 1964. The Nobel Assembly credits Black's team with the first clinically useful beta blockers, pronethalol (1962) and propranolol (1964). Black shared the 1988 Nobel Prize in Physiology or Medicine (Nobel press release, Black biography).
• US approval: Inderal tablets were first approved on 13 November 1967 under NDA 016418, held by Wyeth, as a new molecular entity. That brand is now listed as discontinued (Drugs@FDA).
• UK licence: the current Inderal 10 mg licence is held by Atnahs Pharma UK Ltd and records a first authorisation date of 27 May 1975 (Inderal SmPC).
• Generic status: off-patent and widely generic. The UK medicines compendium lists propranolol from many licence holders, including Sandoz, Aurobindo (Milpharm), Tillomed, Ipca, Flamingo, Rosemont and Amarox (emc search).
• Prescription status: prescription-only in the UK (NHS) and in the US.

How it works

When you are anxious or frightened, your body releases adrenaline and noradrenaline. These make your heart beat faster and cause sweating and shaking. Propranolol blocks the beta receptors that these hormones act on, which reduces the physical signs of anxiety (NHS).

That is the key point for anyone considering it for anxiety. Propranolol mainly works on the body's response. The NHS says it "treats the physical symptoms of anxiety – for example, it stops your heart beating too fast" (NHS). It is not designed to reduce worry, fearful thoughts or avoidance. For some people, stopping a racing heart breaks a vicious circle in which they notice their symptoms and panic about them. For others, the anxious thoughts carry on regardless.

Propranolol does get into the brain. That is part of why it can prevent migraine, and why it can cause vivid dreams and sleep disturbance (HSIB, SmPC). Researchers have also tested whether it can weaken fear memories when they are recalled. A 2016 review found no evidence of this effect on PTSD symptoms (Steenen 2016), and a later randomised trial in dental anxiety found no benefit (Steenen 2022).

Timing: propranolol "usually starts to work in a few hours" (NHS). Peak blood levels come 1 to 2 hours after a dose in fasting people, and the elimination half-life is 3 to 6 hours (SmPC). In older people the half-life can be much longer. One study found 11 hours in people aged 62 to 79, against 5 hours in young adults (FDA label).

What it is prescribed for

UK licensed uses

The UK SmPC lists 11 indications: high blood pressure; angina; long-term protection after a heart attack; most heart rhythm disorders; migraine prevention; essential tremor; "relief of situational anxiety and generalised anxiety symptoms, particularly those of somatic type"; prevention of bleeding from swollen veins in the gullet (oesophageal varices) caused by portal hypertension; thyrotoxicosis; hypertrophic obstructive cardiomyopathy; and phaeochromocytoma around surgery, with an alpha blocker (Inderal SmPC).

US licensed uses

The FDA label we checked lists high blood pressure, angina, atrial fibrillation, after heart attack, migraine prevention, essential tremor, hypertrophic subaortic stenosis and phaeochromocytoma. It has no anxiety indication, so US prescribing for anxiety or stage fright is off-label (FDA label).

Where the heart uses stand today

The NHS says propranolol "used to be a popular treatment" for high blood pressure. It is now considered only when other, more effective medicines have not controlled blood pressure, according to NHS information cited by the HSIB investigation (HSIB, 4.2.2). Its lasting place in heart medicine is reflected in the 1988 Nobel citation, which describes clinical trials showing lower mortality after heart attack (Nobel press release). This article focuses on anxiety, so we do not review the heart evidence in detail.

Where guidelines place it for anxiety

• NICE (UK): the guidelines on generalised anxiety disorder and panic disorder (CG113) and social anxiety disorder (CG159) do not mention propranolol or beta blockers. For GAD they recommend psychological therapy or an SSRI, with sertraline first. For social anxiety they recommend individual CBT first, then an SSRI (escitalopram or sertraline) if the person wants medication (NICE CG113, NICE CG159).
• The gap: the HSIB investigation noted that propranolol is licensed for anxiety symptoms, as reflected in the BNF, but that "clinical guidance regarding when and how it should be used in practice is not available" from NICE. Its recommendation R/2020/069 asked NICE to review and update guidance on propranolol for anxiety and migraine, with particular reference to toxicity in overdose (HSIB).
• NHS patient guidance: "You'll usually only take propranolol for a short time. Many doctors prefer medicine-free treatments for anxiety", such as CBT. It may be prescribed alongside talking therapy to help with physical symptoms (NHS).

How much it is actually used

In UK primary care, the prevalence of beta-blocker prescriptions for anxiety more than doubled, from 3.8 per 1,000 person-years in 2008 to 8.7 per 1,000 in 2018. New prescriptions rose over the whole 16-year study, especially in young adults (Archer et al., BJGP 2022). NHS propranolol prescriptions for all uses rose from 340,958 in May 2014 to 474,233 in July 2019 (HSIB).

What works and what does not

Benefits by claim

Anxiety disorders: the 2016 and 2024 reviews

The first systematic review and meta-analysis of propranolol for anxiety disorders was published in 2016 by a team from the University of Amsterdam and Erasmus University. It searched for randomised trials going back to the first propranolol-and-anxiety paper and found only eight that met its criteria, published between 1981 and 2008 (Steenen et al. 2016). In detail:

• Panic disorder (4 trials, 130 people): three trials could be pooled. They compared propranolol with benzodiazepines (alprazolam or diazepam) and found "no statistically significant differences" in the short term. Doses were high, for example up to 240 mg a day, or 80–320 mg a day with a median of 240 mg.
• Social phobia (1 trial, 16 people): propranolol 160–320 mg a day after social-skills training showed "no significant differences or trends" against placebo on any measure. Three of nine people dropped out of the propranolol group, against one of seven on placebo.
• Specific phobia (2 trials, 37 people): no general effect on subjective anxiety in snake or spider phobia, and no solid evidence in dental phobia.
• PTSD (1 trial, 19 people): no evidence of an effect on symptom severity through blocking fear-memory storage.
• GAD, OCD and other anxiety disorders: no randomised trials found.

Its conclusion, quoted by the national HSIB investigation: "the quality of evidence for the efficacy of propranolol at present is insufficient to support the routine use of propranolol in the treatment of any of the anxiety disorders" (Steenen 2016, HSIB 4.2.7).

A University of Bristol team updated the question in 2024, widening it to all beta blockers and to non-randomised comparison studies. From 3,068 records they included 10 studies, five of which could be meta-analysed (179 people). They found "no evidence for a beneficial effect of beta-blockers compared with either placebo or benzodiazepines" in social phobia or panic disorder, with p-values of 0.54 or higher in every analysis. They called for a large randomised trial (Archer et al. 2025).

What this does and does not mean. "No evidence of benefit" in 179 people is not strong proof that propranolol does nothing. The trials are too small to detect a modest effect. What it does mean is that the rise in prescribing has not been driven by trial evidence. The same Bristol group wrote in 2022 that "some prescribing is not based on robust evidence of effectiveness" (Archer et al., BJGP 2022).

Performance anxiety and stage fright

This is the use most people ask about: a single dose before a presentation, audition, interview or exam. The UK licence covers it as "situational anxiety", with 40 mg daily described as possibly providing "short term relief of acute situational anxiety" (Inderal SmPC).

• Musicians, 1982: two double-blind trials with 29 musicians in total found that beta blockade "eliminates the physical impediments to performance caused by stage fright", including dry mouth, and that music critics rated performances as significantly better. The authors also reported that this was achieved "without tranquilization" (Brantigan et al. 1982).
• Musicians' real-world use: in a 1991 Stanford study of musicians with performance anxiety, 10 of 15 full-time professional musicians had tried propranolol. In that trial, CBT reduced anxiety and improved performance quality, while buspirone did not (Clark and Agras 1991). A 2026 interview study found that classical musicians often see beta blockers as a legitimate tool, mainly for high-stakes auditions (Saltzstein, Hastings Cent Rep 2026).
• Exams: 32 high-school students with test anxiety took 40 mg an hour before retaking the SAT and scored 130 points higher on average. But there was no placebo group, so practice effects cannot be ruled out (Faigel 1991).
• Lab stress: in 12 healthy volunteers, a single 40 mg dose did not reduce anxiety caused by breathing carbon dioxide compared with placebo (Papadopoulos et al. 2010).

Our reading: there is a plausible, physiologically obvious effect on tremor and heart rate, and some small positive trials. There is no modern, large, independent trial in performance anxiety, and we found no systematic review devoted to it. Steenen 2016 did not cover it, because stage fright in otherwise healthy people is not a diagnosed anxiety disorder. A sensible way to read the evidence: propranolol may help people whose main problem in a specific situation is visible shaking or a pounding heart. It is not a treatment for ongoing anxiety.

Placebo response

Anxiety trials usually show large improvements on placebo. In the 2022 dental trial, anxiety scores fell in both arms: from 32.1 to 29.1 on propranolol and from 31.6 to 27.1 on placebo (Steenen 2022). A person who feels better after a tablet before a talk may be experiencing some of this expectation effect.

Risks and all side effects

Common side effects

The NHS lists these as common (more than 1 in 100 people): headaches; feeling tired, dizzy or weak; cold fingers or toes; feeling or being sick; diarrhoea; and difficulty sleeping or nightmares (NHS). The UK SmPC lists these as common (1 in 100 to 1 in 10): sleep disturbances, nightmares, slow heart rate, cold extremities, Raynaud's phenomenon, and fatigue or lassitude, which is often temporary (SmPC).

Serious and less common effects

The overdose problem in detail

The Healthcare Safety Investigation Branch (HSIB) was the national body in England that investigated patient safety incidents; its work continues under the Health Services Safety Investigations Body (HSSIB). It opened a national investigation after the death of a young woman, called "Emma" in the report. She had been prescribed propranolol for migraine and citalopram for depression, and she took an overdose of both. She called 999 while alert, but when the ambulance arrived 56 minutes later she was awake yet unable to speak or move, and she died despite advanced resuscitation (HSIB).

Key findings from the report:

• Deaths linked to propranolol overdose rose 33% between 2012 and 2017, to 52 in 2017. Of those 52, 67% (35) were women.
• 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".
• Prescribing guidance "does not contain sufficient warnings" about toxicity in overdose.
• Emma's repeat prescription routinely contained 6.4 g of propranolol. Fatal overdoses have been recorded after 2 g. She "did not have to stockpile her medication" to take a fatal dose.
• The report made seven safety recommendations. They included asking the BNF (R/2020/068) and NICE (R/2020/069) to review guidance on propranolol for anxiety, and asking the Royal College of GPs and Royal Pharmaceutical Society to help members identify at-risk patients. HSIB also recorded that the MHRA was reviewing the SmPC wording on overdose and interactions, and seeking expert advice on whether the benefit–risk balance "remains favourable in patients presenting with physical symptoms of anxiety".

The current Inderal SmPC (text revised April 2022) now opens its overdose section with "Propranolol is known to cause severe toxicity when used in overdose" and asks that patients be told the signs of overdose (SmPC 4.9). We did not find a published MHRA decision on the anxiety benefit–risk review.

Later independent data point the same way. In coroner-reported suicides in England, Wales and Northern Ireland from 2010 to 2021, 297 of 4,473 (6.6%) involved propranolol, and the proportion rose from 3.4% to 12.3%. Compared with other suicides, those involving propranolol were more often in women (56.6% v 37.1%) and in people diagnosed with anxiety (22.2% v 8.6%). An antidepressant was found at post-mortem in 81.8% (Gorton et al. 2024). An Australian study of 2013–2019 poisoning suicides listed propranolol among the medicines with high toxicity relative to how widely they are used (Lim et al., MJA 2025).

Why this matters for anxiety prescribing: people with anxiety are more likely than average to also have depression or self-harm thoughts. A drug with weak evidence of benefit, prescribed in large quantities to this group, carries a risk that is easy to overlook. After Emma's death, her GP practice limited propranolol to a 28-day supply for patients who also have depression (HSIB, A/2020/025).

Dependence and withdrawal

Propranolol is not addictive in the way benzodiazepines are, and it is not a controlled drug. Stopping suddenly after long-term use can still cause rebound symptoms: an irregular heart rate, sweating and shaking, which can feel like anxiety returning. The NHS says your doctor will usually reduce the dose over 1 to 2 weeks, and that side effects from stopping can last up to a week (NHS). For anxiety used long term, the NHS says "there do not seem to be any lasting harmful effects if you take it for several months or years", but blood pressure should be checked regularly (NHS).

All interactions

Who should avoid propranolol

Must not take it (contraindications)

According to the UK SmPC: anyone with a history of bronchial asthma or bronchospasm; a slow heart rate; cardiogenic shock; low blood pressure; metabolic acidosis; after prolonged fasting; severe circulation problems in the limbs; second- or third-degree heart block; sick sinus syndrome; untreated phaeochromocytoma; uncontrolled heart failure; Prinzmetal's angina; and people prone to hypoglycaemia (Inderal SmPC).

Tell your prescriber first if you

• have ever had depression or thoughts of harming yourself (NHS). This matters especially for anxiety prescribing, because of the overdose risk above.
• have diabetes, liver or kidney problems, Raynaud's or other circulation problems, or lung disease (NHS).
• have first-degree heart block, controlled heart failure, psoriasis, myasthenia gravis, an overactive thyroid, or a history of severe allergic reactions (SmPC).
• compete in sport at a high level: "in some sports propranolol is not allowed" (NHS).

Pregnancy and breastfeeding

The NHS says propranolol can be taken in pregnancy, but it "can sometimes affect your baby's growth", so extra growth scans are usually offered from 32 weeks. It passes into breast milk in tiny amounts and is generally considered OK if the baby is healthy (NHS). The SmPC is more cautious: it should not be given in pregnancy unless essential, because beta blockers reduce blood flow to the placenta and can cause a slow heart rate and low blood sugar in the newborn. It also says breastfeeding is "not recommended" (SmPC). For anxiety alone, where the evidence of benefit is weak, this balance deserves a careful conversation with your prescriber.

Older adults

Treatment should start at the lowest dose (SmPC). Clearance falls with age, and the half-life can double (FDA label). The NHS says doses are usually lower over 65 and with kidney or liver problems (NHS). Older people are at higher risk of severe heart complications in overdose (SmPC 4.9).

Children and young people

Most adults and children aged 12 and over can take it (NHS). Prescriptions for anxiety have risen fastest in young adults (Archer 2022).

Dosage and how to take it

Your prescriber sets the dose. The ranges below are the official licensed adult doses, given for reference only.

Note how low the anxiety doses are compared with the heart doses. The early anxiety trials used much higher doses, often 160–320 mg a day (Steenen 2016), so the evidence and the licensed anxiety doses do not line up well.

• How to take it: tablets come in 10, 40, 80 and 160 mg; slow-release capsules in 80 and 160 mg. Swallow with water, with or without food, and do not crush slow-release capsules. The NHS suggests taking the first once-daily dose at bedtime in case it makes you dizzy (NHS).
• How soon it works: usually within a few hours for physical anxiety symptoms (NHS).
• How long to take it: for anxiety, usually a short time. Talk to your doctor about the risks and benefits of taking it for more than a few months (NHS).
• Missed dose: take it when you remember unless it is nearly time for the next one. Never double up (NHS).
• Stopping: only with your prescriber, usually by tapering over 1 to 2 weeks (NHS) or 7 to 14 days (SmPC). People with heart disease need closer follow-up.
• Keeping supplies small: if you or someone in your household is at risk of self-harm, ask your prescriber about smaller supplies. After the HSIB case, one GP practice limited propranolol to 28 days for patients with depression (HSIB).

Follow the money: who makes it and who funded the evidence

Who made it

Propranolol came from the pharmaceutical research of ICI, a British company, where James Black led the beta-blocker programme from 1958 to 1964. Propranolol followed pronethalol and was reported in 1964 (Nobel biography, Nobel press release). In the US, Wyeth held the original Inderal approval from 1967 (Drugs@FDA). We did not verify the licensing arrangement between ICI and Wyeth.

Who sells it now

• UK brand: Inderal is held by Atnahs Pharma UK Ltd of Basildon, Essex, whose contact details point to pharmanovia.com (SmPC). We did not verify Atnahs's ownership.
• US brand: Inderal LA and InnoPran XL are held by ANI Pharmaceuticals (Drugs@FDA).
• Generics: the openFDA Drugs@FDA database lists 150 application records containing propranolol hydrochloride, and the UK compendium lists more than ten licence holders (openFDA, emc).
• Revenue: propranolol is a cheap, decades-old generic. We found no documented brand revenue figure. There is no large company with a strong commercial stake in promoting it for anxiety, which is unusual among the medicines we review.

Who funded the evidence

• The anxiety licence: the UK anxiety indication appears in the SmPC, but we could not find the original trials submitted for it. Its first UK authorisation date (1975 for the current Inderal 10 mg licence) is decades older than modern trial standards.
• The anxiety trials: the eight randomised trials in the 2016 review were small studies from 1981 to 2008. The review extracted funding sources, but they are not summarised in the abstract. We did not verify funding for the 1982 stage-fright trials.
• The independent reviews: Steenen 2016 had no external funding and no conflicts. The Bristol reviews and prescribing studies were funded through the NIHR (the UK's public health research funder) and NHS bodies, with no competing interests declared (Archer 2022, Gorton 2024).
• The safety evidence: it comes from a UK government safety investigator, the Office for National Statistics (via HSIB) and academic coroner-data research. None of it is manufacturer-funded.

The money pattern here is the reverse of most psychiatric drugs. The evidence is almost entirely independent, but there is very little of it, because no company has had a reason to pay for a large modern anxiety trial of a cheap generic. The Bristol researchers have called for exactly such a trial (Archer 2025).

Related research

• Stress, anxiety and depression: evidence-based prevention guide
• Supplements for stress, anxiety and depression: the evidence
• Hydroxyzine: independent evidence, another short-term anxiety medicine with its own heart-rhythm warning
• Sertraline · Escitalopram: NICE's first-choice medicines for GAD and social anxiety
• Citalopram, the antidepressant most often found alongside propranolol in overdose deaths
• Pregabalin · Buspirone · Diazepam · Alprazolam
• L-theanine · Magnesium · Ashwagandha · Saffron
• Sleep prevention guide · Sleep supplements evidence

Frequently asked questions

Sources and funding notes

• NHS: About propranolol, with the linked pages on how and when to take it, side effects, who can and cannot take it, pregnancy and breastfeeding, other medicines and common questions (reviewed 6 January 2026): UK public health service; no commercial funding.
• Inderal 10 mg Summary of Product Characteristics (Atnahs Pharma UK), revised April 2022: licence holder's document, approved by the MHRA. Also generic propranolol SmPC (Milpharm), identical anxiety indication, and the emc product listing.
• US FDA label, propranolol hydrochloride tablets (DailyMed, 2024): FDA-approved generic label; US government regulator.
• Drugs@FDA: Inderal NDA 016418 (Wyeth, 1967) and Inderal LA NDA 018553 (ANI), via openFDA: US government records.
• HSIB: Potential under-recognised risk of harm from the use of propranolol (investigation report): UK government-funded independent safety investigator (now HSSIB); cites ONS death data.
• Steenen et al., Propranolol for the treatment of anxiety disorders: systematic review and meta-analysis, J Psychopharmacol 2016 (full text): Dutch academic; "no financial support"; no conflicts declared.
• Archer et al., Beta-blockers for the treatment of anxiety disorders: systematic review and meta-analysis, J Affect Disord 2025: UK academic (Bristol); no competing interests; funding statement not seen in the abstract record.
• Archer et al., Rise in prescribing for anxiety in UK primary care 2003–2018, BJGP 2022 (full text): UK academic; funded by the NIHR School for Primary Care Research.
• Gorton et al., Involvement of propranolol in suicides: coroner-reported data, BJPsych Open 2024 (full text): UK academic; NIHR and NHS Integrated Care Board fellowships; no conflicts declared.
• Lim et al., Relative toxicity of medicines in poisoning suicide deaths in Australia, MJA 2025: Australian academic; one author declared unrelated grants from Reckitt.
• Steenen et al., Perioperative propranolol against dental anxiety: randomised controlled trial, Front Psychiatry 2022: Dutch academic; no conflicts declared.
• Brantigan et al., Effect of beta blockade and beta stimulation on stage fright, Am J Med 1982: US; funding not shown in the abstract record.
• Clark and Agras, Assessment and treatment of performance anxiety in musicians, Am J Psychiatry 1991: US academic (Stanford); funding not shown in the abstract record.
• Faigel, Beta blockade and stress-induced cognitive dysfunction in adolescents, Clin Pediatr 1991: US university health service; uncontrolled; funding not shown.
• Liebowitz et al., Phenelzine vs atenolol in social phobia, Arch Gen Psychiatry 1992: US academic (New York State Psychiatric Institute); funding not shown in the abstract record.
• Papadopoulos et al., Single-dose anxiolytics in CO2 models of anxiety, J Psychopharmacol 2010: UK academic (Bristol); funding not shown in the abstract record.
• Saltzstein, Musical performance and biomedical human enhancement, Hastings Cent Rep 2026: US ethnographic study; used only to describe musicians' attitudes.
• NICE CG113: Generalised anxiety disorder and panic disorder in adults and NICE CG159: Social anxiety disorder: UK public body, mainly government-funded.
• Nobel Assembly at Karolinska Institutet: 1988 Nobel Prize press release and Sir James Black biographical note: historical record; no commercial interest.

Last reviewed: 26 September 2026. Educational information from Pure City Research, not medical advice. Medicine decisions belong with a qualified prescriber.