Can I use hydroxyzine for compulsive thoughts in the US, having previously been prescribed clotiazepam (clotiazepam) for obsessive-compulsive disorder (OCD) in Chile?

Hydroxyzine Is Not Recommended for Obsessive-Compulsive Disorder

Hydroxyzine should not be used as a substitute for clotiazepam in treating obsessive-compulsive disorder (OCD) as it lacks evidence for efficacy in this condition. SSRIs are the first-line pharmacological treatment for OCD, not antihistamines like hydroxyzine 1.

First-Line Treatment Options for OCD

Recommended Medications

• SSRIs are the first-line pharmacological treatment for OCD 1:

  • Fluoxetine (20-80 mg/day)
  • Sertraline (50-200 mg/day)
  • Fluvoxamine

• Clomipramine is an effective alternative when SSRIs are ineffective 1

Why Hydroxyzine Is Not Appropriate for OCD

1. FDA Indication: Hydroxyzine is only approved for "symptomatic relief of anxiety and tension associated with psychoneurosis" 2, not for OCD which requires different treatment approaches
2. Mechanism of Action: OCD requires serotonergic modulation, while hydroxyzine is an antihistamine without significant serotonergic effects 2
3. Evidence Gap: No clinical evidence supports hydroxyzine for obsessive thoughts or OCD symptoms 3

Understanding Clotiazepam vs. Hydroxyzine

Clotiazepam

• Benzodiazepine with anxiolytic properties
• May have been used for anxiety symptoms associated with OCD, not for core OCD symptoms 4
• Not FDA-approved in the United States

Hydroxyzine

• Antihistamine with sedative and anxiolytic properties
• FDA-approved for anxiety associated with psychoneurosis 2
• Common side effects include sedation and drowsiness 2
• Not indicated for treatment of obsessive thoughts or compulsions

Appropriate Treatment Algorithm for OCD

1. First-line: SSRI at adequate dosage (higher doses than for depression) for 8-12 weeks 1

   • Fluoxetine, sertraline, or fluvoxamine

2. Second-line (if inadequate response to first SSRI):

   • Switch to another SSRI
   • Try clomipramine (with caution regarding side effects) 1

3. Augmentation strategies (for partial response):

   • Add antipsychotic (risperidone or aripiprazole)
   • Consider glutamatergic agents (N-acetylcysteine, memantine) 1

4. Non-pharmacological approach:

   • CBT with exposure and response prevention (CBT-ERP) - most evidence-based psychotherapy for OCD 1
   • Can be used alone or in combination with medication

Important Considerations

• Medication Discontinuation: Abrupt discontinuation of clotiazepam (benzodiazepine) can lead to withdrawal symptoms; gradual tapering is recommended 5
• Cross-Border Medication Issues: Medications approved in other countries may not be available or approved for the same indications in the US
• Benzodiazepine Risks: Long-term use of benzodiazepines like clotiazepam can lead to tolerance, dependence, and withdrawal effects 6
• Chemical Restraint Concerns: Hydroxyzine has been used as a chemical restraint in acute agitation but is not appropriate for chronic management of OCD 5

Bottom Line

For a patient previously treated with clotiazepam for OCD who is now in the US, the appropriate approach is to consult with a psychiatrist for initiation of an SSRI (fluoxetine, sertraline, or fluvoxamine) and/or referral for CBT-ERP therapy. Hydroxyzine is not an appropriate substitute for treating the core symptoms of OCD, though it might help temporarily with associated anxiety or sleep disturbance as an adjunct to proper OCD treatment.