What is the role of Vistaril (hydroxyzine) in the management of anxiety?

Vistaril (Hydroxyzine) for Anxiety

Vistaril (hydroxyzine) should be reserved as a second-line or alternative pharmacologic option for anxiety, used only when first-line psychological/behavioral treatments are inaccessible, when patients prefer medication, or when evidence-based therapies have failed. 1

Treatment Hierarchy for Anxiety Management

First-Line Treatments (Strongly Recommended)

For patients with moderate anxiety symptoms, prioritize non-pharmacologic interventions 1:

• Cognitive Behavioral Therapy (CBT) - strongest evidence base with consistent reductions in anxiety symptoms 1
• Behavioral Activation (BA) 1
• Structured physical activity and exercise - moderate to large effect sizes demonstrated 1
• Psychosocial interventions with empirically supported components (relaxation, problem-solving) 1

Second-Line: Pharmacologic Treatment

Pharmacologic regimens, including hydroxyzine, may be offered only when 1:

• Patients lack access to first-line psychological/behavioral treatments
• Patients express a preference for pharmacotherapy
• Patients have not improved following first-line management

Important caveat: The evidence quality for pharmacologic management of anxiety is LOW with only WEAK strength of recommendation 1

Hydroxyzine-Specific Evidence

FDA-Approved Indication

Hydroxyzine is FDA-approved for "symptomatic relief of anxiety and tension associated with psychoneurosis," though the effectiveness for long-term use (>4 months) has not been assessed by systematic clinical studies 2

Clinical Trial Data

• Efficacy vs. placebo: Hydroxyzine 50 mg/day demonstrated statistically significant anxiolytic effect beginning in the first week of treatment 3, 4
• Comparative effectiveness: When compared to benzodiazepines and buspirone, hydroxyzine showed equivalent efficacy 3
• Quality concerns: A 2010 Cochrane review concluded that due to high risk of bias in included studies, small sample sizes, and limited number of trials, hydroxyzine cannot be recommended as a reliable first-line treatment in GAD 3

Adverse Effects Profile

The most common side effect is sleepiness/drowsiness (28% vs 14% with placebo), which typically appears during the first week and progressively diminishes 4:

• Dry mouth (14% vs 5% placebo) 4
• Weight gain (12% vs 10% placebo) 4
• Loss of concentration (9% vs 8% placebo) 4
• Insomnia (9% vs 6% placebo) 4

Critical limitation: Hydroxyzine was associated with higher rates of sedation compared to other anxiolytics 3

Clinical Decision Algorithm

1. Screen and assess anxiety severity - use validated measures 1

2. Provide patient education about anxiety symptoms, commonality, and when to contact medical team 1

3. For moderate anxiety: Offer CBT, BA, structured exercise, or psychosocial interventions as first-line 1

4. Consider hydroxyzine only if:

   • First-line treatments unavailable or failed 1
   • Patient preference for medication 1
   • Short-term use anticipated (<4 months) 2

5. If prescribing hydroxyzine:

   • Typical dose: 50 mg/day 4
   • Warn patients about transient sedation in first week 4
   • Reassess periodically for continued need 2
   • Monitor for cognitive impairment, especially in elderly 4

6. If no response to hydroxyzine: Reevaluate for depression and other psychiatric comorbidity; consider SSRIs, SNRIs, or buspirone which have stronger evidence bases 1, 5

Common Pitfalls to Avoid

• Do not use hydroxyzine as first-line treatment when evidence-based psychological interventions are available 1, 3
• Avoid long-term use beyond 4 months without systematic reassessment, as efficacy data is lacking 2
• Do not overlook sedation risk - particularly problematic for patients who drive or operate machinery 3, 4
• Recognize limited evidence quality - the recommendation for any pharmacotherapy in anxiety has only LOW evidence quality 1