What is the treatment for anxiety?

Treatment of Anxiety with Vistaril (Hydroxyzine)

Vistaril (hydroxyzine) is not recommended as a first-line treatment for anxiety disorders based on current clinical practice guidelines, which consistently prioritize SSRIs, SNRIs, and cognitive behavioral therapy instead. 1, 2

First-Line Treatment Recommendations

Pharmacotherapy Options

• SSRIs are the preferred first-line medications for anxiety disorders due to their favorable side effect profiles and robust evidence base 1, 2, 3

  • Sertraline and escitalopram have the most favorable safety profiles for most patients 2
  • Other effective SSRIs include fluoxetine, paroxetine, fluvoxamine, and citalopram 1, 2
  • SSRIs demonstrate moderate to high effectiveness with areas under the receiver-operating characteristic curve ranging from 0.77 to 0.94 1

• SNRIs, particularly venlafaxine, are equally effective as first-line alternatives with similar efficacy to SSRIs 2, 3

  • Meta-analyses show SSRIs and SNRIs produce small to medium effect sizes compared to placebo (standardized mean difference -0.30 to -0.67 depending on anxiety disorder type) 3

Psychotherapy as First-Line Treatment

• Cognitive Behavioral Therapy (CBT) is the psychotherapy with the highest level of evidence for anxiety disorders 1, 2, 3
  • CBT should be structured with approximately 14 sessions over 4 months, with individual sessions lasting 60-90 minutes 2
  • Core CBT elements include: education about anxiety, behavioral goal setting, self-monitoring, relaxation techniques, cognitive restructuring, graduated exposure, and problem-solving 1, 2
  • Individual CBT sessions are generally preferred over group therapy due to superior clinical effectiveness 2

Treatment Algorithm

Start with either an SSRI, SNRI, or CBT based on patient preference and access 2, 3

1. Initial treatment selection:

   • For pharmacotherapy: Begin with sertraline or escitalopram at standard starting doses 2, 4
   • For psychotherapy: Initiate structured CBT with a trained therapist 1, 2
   • Combination treatment with CBT and medication may be considered for optimal outcomes 2

2. If first treatment fails:

   • Switch to another SSRI or SNRI 2
   • Consider adding CBT if medication alone was tried initially 2

3. Treatment duration:

   • Continue medications for at least 6-12 months after symptom remission 2, 5, 6
   • Taper gradually to avoid discontinuation syndrome 2, 4

Second-Line Treatment Options

Benzodiazepines (such as alprazolam) are considered second-line treatments and are not recommended for routine use due to dependency risk, somnolence, and memory disturbances 2, 7, 5

• If benzodiazepines are necessary, use lower doses with shorter half-lives, especially in elderly patients 2
• Alprazolam dosing for anxiety: initiate at 0.25-0.5 mg three times daily, with maximum daily dose of 4 mg in divided doses 8
• Critical caveat: Benzodiazepines carry significant addiction potential and should be avoided for routine use 5, 6

Other second-line options include:

• Pregabalin and gabapentin 2, 5, 6
• Tricyclic antidepressants 2, 5
• Buspirone 2, 5, 6

Special Populations

For elderly patients:

• Sertraline and escitalopram are preferred due to lower potential for drug interactions 2
• Use lower or less frequent dosing 4

For pregnant women:

• Carefully weigh risks and benefits when treating during third trimester 4
• Consider tapering SSRIs in the third trimester due to neonatal complications 4

Common Pitfalls to Avoid

• Do not use beta blockers (atenolol, propranolol) - they are not recommended based on negative evidence 2
• Avoid antipsychotics like quetiapine as first-line treatment 2
• Use paroxetine cautiously due to higher risk of discontinuation syndrome and potential increased risk of suicidal thinking 2
• Never abruptly discontinue SSRIs - always taper gradually, particularly with paroxetine, fluvoxamine, and sertraline 2, 4
• Do not undertreat - anxiety disorders are chronic conditions requiring adequate duration of treatment (6-12 months minimum after remission) 2, 5, 9