- Anti-Anxiety Medications Explained
- Atarax Tablet
- Hydroxyzine: Rational choice for inpatients with insomnia
- Generic Name: Hydroxyzine (hye-DROX-ee-zeen)
Anti-Anxiety Medications Explained
Americans’ use of anti-anxiety medications has increased dramatically, and while medications can play an important role in the treatment of anxiety disorders, they are not risk-free and in some cases may exacerbate a problem. Nonetheless, because anti-anxiety medications work quickly and involve less effort than psychotherapy, they are a popular choice of treatment among both doctors and patients. This may be particularly true in the primary-care setting, where anxiety disorders are frequently treated.
First, a word about therapy. Cognitive Behavioral Therapy has been shown to be as effective as medications for anxiety disorders and is considered to be first-line treatment for these conditions. The advantage of psychotherapy over medications is that the benefits tend to persist beyond the end of treatment. The reason for this is easy to see: Recovery achieved in therapy occurs via learning, and when you have learned that something isn’t dangerous you don’t fear it anymore. Conversely, when anxiety is treated by using a medication, the recovery often depends on the continued use of that medication. Often, the best results are achieved when therapy and medications are combined.
Types of Anti-Anxiety Medications
Not all anti-anxiety medications are the same, and it is important to make a distinction between the different classes used to treat anxiety. The risks and benefits associated with each medication class can vary dramatically. Further, certain medications often used for anxiety may actually decrease the efficacy of psychotherapy being administered at the same time.
The following are the main classes of medications typically used to treat anxiety and their associated risks and benefits, along with some examples of specific medications in each class.
Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs are one of the most commonly used types of medication for anxiety and are often a psychiatrist’s first choice for this purpose. SSRIs have been proven to be very effective for anxiety, are non-addictive, don’t cause memory impairment or interfere with psychotherapy, and have minimal side effects. When SSRIs do cause side effects, they usually subside within the first week. A notable exception, however, is decreased sexual sensation, which occurs in a significant minority of patients.
Some additional disadvantages of SSRIs are that that they take 4-to-6 weeks to reach maximum efficacy and certain SSRIs can cause uncomfortable withdrawal symptoms if stopped abruptly. For individuals with bipolar disorder, SSRIs may trigger a manic episode; for this reason, they are given to these patients with a mood stabilizer. There is also some evidence that SSRIs may increase the risk of suicide among younger patients.
SSRIs work by increasing the amount of signaling between neurons that use a chemical called serotonin to communicate with each other. They are also used to treat depression. Currently available SSRIs include Prozac (fluoxetine), Celexa (citalopram), Lexapro (escitalopram), Zoloft (sertraline), Paxil (paroxetine), and Luvox (fluvoxamine).
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs). SNRIs do the same thing that SSRIs do but they also increase the amount of signaling between neurons that use a chemical called norepinephrine to communicate with one another. When used to treat anxiety, the benefits and side effects of SNRIs are essentially the same as those for SSRIs. Like the SSRI, the SNRIs take 4-to-6 weeks to reach maximum effect. The three currently available SNRIs are Effexor (venlafaxine), Cymbalta (duloxetine), and Pristiq (desvenlafaxine).
Benzodiazepines. This class of medication includes the well-known drugs Valium (diazepam), Xanax (alprazolam), Klonopin (clonazepam), and Ativan (lorazepam). Although benzodiazepines are prescribed frequently for anxiety, particularly by non-psychiatrists, they are no longer considered to be a first-line treatment for these conditions. They reduce anxiety quickly; however, they can cause problems when taken long-term and should be used with caution.
Benzodiazepines cause tolerance, which means that over time more of the drug needs to be taken to achieve the same effect. There is also a withdrawal syndrome associated with these medications which in the extreme can cause seizures and even death. Further, certain individuals may develop an addiction to these medications. Benzodiazepines also inhibit the formation of new memories which can have a negative impact on psychotherapy. And these medications can be lethal when combined with alcohol or opioids and are involved in a significant percentage of fatal overdoses.
Nonetheless, when used appropriately, benzodiazepines can play an important role in the treatment of an anxiety disorder. For example, they are sometimes used in combination with an SSRI for the first few weeks of treatment before the SSRI reaches maximum efficacy. Long-term treatment with a benzodiazepine may be appropriate for some individuals with anxiety but is not considered to be first-line treatment and should only be used in this way under the care of a psychiatrist.
Buspirone. Buspar (buspirone) is a medication sometimes used to treat anxiety. Like SSRIs, buspirone works by influencing the neurons which use serotonin to communicate, but unlike SSRIs, which increase the amount of serotonin available to all serotonin receptors, buspirone affects only one specific subtype of serotonin receptor. An advantage of this selectivity is that buspirone does not cause the sexual side effects sometimes associated with SSRIs. Like SSRIs and SNRIs, buspirone may take 4-to-6 weeks to reach maximum efficacy.
Hydroxyzine. Vistaril (hydroxyzine) is sometimes used to treat anxiety. Like benzodiazepines, hydroxyzine’s effects occur quickly. Unlike benzodiazepines, hydroxyzine is non-habit forming and does not cause tolerance, withdrawal, or memory impairment. The most significant side effect of hydroxyzine is sedation, but this tends to decrease over time. The anti-anxiety effects of hydroxyzine are thought to be due to its blocking of the histamine receptor; however, hydroxyzine appears to be more effective for anxiety than other antihistamines (such as Benadryl); this may be due to its interaction with a subset of serotonin receptors.
Gabapentin. Neurontin (gabapentin) is primarily used to treat seizures and nerve pain but is also used with some frequency by psychiatrists to treat anxiety. Like hydroxyzine, gabapentin works quickly and without many of the problems associated with benzodiazepines. However, there may be a withdrawal syndrome associated with gabapentin and some patients experience significant drowsiness. Like SSRIs, gabapentin may also be associated with an increased risk of suicide.
Because gabapentin has “gaba” in its name, it is often mistakenly believed to directly affect neurons that use a chemical called GABA to communicate with one another (which is how benzodiazepines work). The exact mechanism by which gabapentin achieves its effects is unknown but may involve binding to a cellular structure that moves calcium across the cell membrane.
This is not a complete list of the medications used to treat anxiety, and a psychiatrist may opt to use something else depending on the specific circumstances. Further, some medications listed above do not have an FDA indication for anxiety disorder but are included here because they are frequently used off-label for this purpose. Given the large number of medications that are used for anxiety and their sometimes serious side effects, it is important that these medications be used only under the care of a physician. Further, the long-term efficacy and minimal side effects of cognitive behavioral therapy make it an excellent treatment for anxiety disorders and it should always be a consideration regardless of whether medications are used.
Before taking hydroxyzine, tell your doctor or pharmacist if you are allergic to it; or to cetirizine; or to levocetirizine; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.
Before using this medication, tell your doctor or pharmacist your medical history, especially of: breathing problems (such as emphysema, asthma), high pressure in the eye (glaucoma), high blood pressure, kidney problems, liver problems, seizures, stomach/intestine problems (such as ulcer, blockage), overactive thyroid (hyperthyroidism), difficulty urinating (for example, due to enlarged prostate).
Hydroxyzine may cause a condition that affects the heart rhythm (QT prolongation). QT prolongation can rarely cause serious (rarely fatal) fast/irregular heartbeat and other symptoms (such as severe dizziness, fainting) that need medical attention right away.
The risk of QT prolongation may be increased if you have certain medical conditions or are taking other drugs that may cause QT prolongation. Before taking hydroxyzine, tell your doctor or pharmacist of all the drugs you take and if you have any of the following conditions: certain heart problems (heart failure, slow heartbeat, QT prolongation in the EKG), family history of certain heart problems (QT prolongation in the EKG, sudden cardiac death).
Low levels of potassium or magnesium in the blood may also increase your risk of QT prolongation. This risk may increase if you use certain drugs (such as diuretics/”water pills”) or if you have conditions such as severe sweating, diarrhea, or vomiting. Talk to your doctor about taking hydroxyzine safely.
This drug may make you dizzy or drowsy or blur your vision. Alcohol or marijuana (cannabis) can make you more dizzy or drowsy. Do not drive, use machinery, or do anything that needs alertness or clear vision until you can do it safely. Avoid alcoholic beverages. Talk to your doctor if you are using marijuana (cannabis).
Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).
Liquid products may contain sugar and/or alcohol. Caution is advised if you have diabetes, liver disease, or any other condition that requires you to limit/avoid these substances in your diet. Ask your doctor or pharmacist about using this product safely.
Children may be more sensitive to the side effects of this drug. This drug can often cause excitement in young children instead of drowsiness.
Older adults may be more sensitive to the side effects of this drug, especially drowsiness, confusion, constipation, trouble urinating or QT prolongation (see above). Drowsiness and confusion can increase the risk of falling.
During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.
It is unknown if this drug passes into breast milk. Consult your doctor before breast-feeding.
Hydroxyzine: Rational choice for inpatients with insomnia
Many physicians prescribe hypnotics for hospitalized patients with insomnia. Frequently used medications include temazepam, diphenhydramine, quetiapine, and trazodone. We have found hydroxyzine, 25 mg to 100 mg nightly, to be effective in adults and geriatric patients and feel it is a more rational choice.
Temazepam and other benzodiazepines may cause behavioral disinhibition, delirium (particularly in geriatric patients), and development of tolerance,1 which may lead to withdrawal symptoms after discharge. Diphenhydramine, quetiapine, and trazodone are effective as hypnotics through antihistaminergic mechanisms, but efficacy can be compromised by adverse effects mediated by non-histaminergic receptor activity. For example, at doses used for sleep, quetiapine can cause weight gain,2 extrapyramidal symptoms, and orthostasis. Trazodone also causes orthostasis and, infrequently, priapism. Because of its relatively high affinity for acetylcholine receptors, diphenhydramine can cause constipation and urinary retention, worsen cognitive function, and exacerbate delirium, particularly in geriatric patients.3
Hydroxyzine is a more selective anti-histamine than the aforementioned molecules,4 which leads to the sleep-promoting benefits of Hl-receptor blockade without significant alpha-1 adrenergic antagonism or anticholinergic side effects. The ratio of affinity for H1 receptors to cerebral acetylcholine receptors is more than 10 times greater for hydroxyzine than for diphenhydramine. Similarly, hydroxyzine has greater affinity for H1 receptors than alpha-1 adrenergic receptors, while trazodone has greater affinity for alpha-1 adrenergic receptors than for H1 receptors. Additionally, hydroxyzine does not lead to tolerance.5 Finally, it has a potential economic advantage over on-patent drugs such as quetiapine.
A disadvantage to hydroxyzine is its comparatively long half-life of 20 hours. Although this can lead to daytime sedation after nighttime dosing, we have not found this to be clinically significant for most patients.
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Generic Name: Hydroxyzine (hye-DROX-ee-zeen)
Drug Class: Antihistamine
Table of Contents
- How to Take It
- Side Effects
- Warnings & Precautions
- Drug Interactions
- Dosage & Missing a Dose
- Pregnancy or Nursing
- More Information
Atarax (hydroxyzine) is an antihistamine used to treat itching, sneezing and runny nose from allergies. It is also used as a sedative to treat (short term) anxiety and tension. It is also used together with other medications given for anesthesia. Atarax is also used to treat allergic skin reactions, e.g., contact dermatitis or hives.
This information is for educational purposes only. Not every known side effect, adverse effect, or drug interaction is in this database. If you have questions about your medicines, talk to your health care provider.
It works by reducing activity in the central nervous system. It also acts as an antihistamine that reduces the natural chemical histamine in the body. Histamine can produce symptoms of sneezing and runny nose, or hives on the skin.
How to Take It
Follow the directions for using this medicine provided by your doctor. This medicine should be taken with a full glass of water. Continue to take this medicine even if you feel well. Do not miss any doses.
Side effects that may occur while taking this medicine include:
- dry mouth
- blurred vision
Contact your doctor immediately if you experience:
- mental changes
- mood changes
- shaking (tremor)
- facial swelling
- difficulty urinating
- heartbeat that is fast or irregular
Warnings & Precautions
- Atarax may cause impaired thinking and reactions. DO NOT operate machinery or drive a vehicle until you know how you react to this medicine.
- Inform your doctor if you are allergic to Atarax, cetirizine, or levocetirizine. Let your doctor know if you have any other allergies.
- Talk with your doctor about any other medications you are taking that make you drowsy, including narcotic pain medicine, cold / allergy medicine, sedatives, sleeping pills, or muscle relaxers.
- Avoid alcohol while taking this medication. Alcoholic beverages can increase certain side effects of hydroxyzine.
- If you are taking the liquid form of this medication, use caution if you have liver disease, diabetes, or any other condition that requires you to limit/avoid sugar in your diet.
- For an overdose, seek medical attention immediately. For non-emergencies, contact your local or regional poison control center at 1-800-222-1222.
Before taking any new medicine, either prescription or over-the-counter, check with your doctor or pharmacist. This includes supplements and herbal products.
Dosage & Missed Dose
Take Atarax exactly as prescribed by your physician. Follow the directions on your prescription label. Carefully measure the dose using the included spoon if you are taking the liquid form of this medication.
If you skip a dose, take your next dose as soon as you remember. If it is time for your next dose, skip the missed dose and go back to your regular schedule. Do not double doses or take extra medicine to make up for the missed dose.
Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (preferably not in the bathroom). Throw away any medication that is outdated or no longer needed.
Consult with your doctor if you are pregnant. This medication could harm an unborn baby. Use effective birth control, and tell your doctor if you become pregnant during treatment. Talk to your doctor if you are planning to breast-feed your baby. It is not known if Atarax will pass into breast milk.
For more information, talk to your doctor, pharmacist or health care provider, or you can visit this website, https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682866.html for additional information from the manufacturer of this drug.