Hydroxyzine for Managing Anxiety and Insomnia During SSRI Withdrawal
Hydroxyzine is an appropriate short-term option for managing anxiety and insomnia symptoms during escitalopram withdrawal until the patient can see their psychiatrist.
Rationale for Using Hydroxyzine
Hydroxyzine is FDA-approved for "symptomatic relief of anxiety and tension associated with psychoneurosis" and can be used as a sedative 1. Its antihistamine properties make it particularly useful for addressing both anxiety and insomnia that commonly occur during SSRI withdrawal.
Benefits of hydroxyzine in this scenario:
- Non-habit forming (unlike benzodiazepines)
- Rapid onset of action for symptom relief
- Does not interact with escitalopram's metabolic pathway
- Can address both anxiety and sleep disturbances simultaneously
Dosing Recommendations
- For anxiety symptoms: 25-50 mg 3-4 times daily as needed
- For insomnia: 25-50 mg at bedtime
Start with the lower dose (25 mg) and increase as needed based on symptom response and tolerability. The sedating effects make it particularly useful for nighttime dosing to address insomnia.
Monitoring and Precautions
Common side effects to monitor:
- Drowsiness/sedation (most common)
- Dry mouth
- Dizziness
- Headache
Important precautions:
- Advise patient about potential daytime drowsiness and to avoid driving or operating machinery until effects are known
- Monitor for excessive sedation, especially in older adults
- Use with caution in patients taking other CNS depressants
- Rare but serious: Watch for signs of QT prolongation in patients with cardiac risk factors
Duration of Use
Hydroxyzine should be used as a short-term bridge until psychiatric follow-up. The FDA label notes: "The effectiveness of hydroxyzine as an antianxiety agent for long-term use, that is more than 4 months, has not been assessed by systematic clinical studies" 1.
Alternative Options
If hydroxyzine is ineffective or not tolerated:
For insomnia:
For anxiety:
- Non-pharmacological approaches like cognitive behavioral therapy should be encouraged
- Consider referral for more urgent psychiatric evaluation if symptoms are severe
Evidence Supporting This Approach
Hydroxyzine has demonstrated efficacy in treating generalized anxiety disorder compared to placebo 4, 5 and has been used successfully to manage symptoms during benzodiazepine withdrawal 6. Its dual action on anxiety and sleep makes it particularly suitable for managing SSRI withdrawal symptoms.
Important Considerations
- Avoid combining hydroxyzine with other highly sedating medications
- Do not abruptly discontinue escitalopram if possible - tapering is preferred to minimize withdrawal symptoms
- Reassure the patient that most SSRI withdrawal symptoms are temporary and will resolve with time
- Document that this is a short-term intervention pending psychiatric follow-up
By providing hydroxyzine as a bridge therapy, you can help manage the patient's anxiety and insomnia symptoms until they can receive definitive management from their psychiatrist.