From the Guidelines
Doxepin is not the first-line treatment for hypervigilance, and its use should be considered only when first-line treatments, such as SSRIs and psychotherapy, have failed or are not tolerated. Doxepin is a tricyclic antidepressant that can be prescribed for anxiety, insomnia, and depression, which may accompany hypervigilance 1. For hypervigilance specifically, which often occurs as part of PTSD or anxiety disorders, first-line treatments typically include SSRIs like sertraline (50-200 mg daily) or paroxetine (20-50 mg daily), along with psychotherapy such as cognitive behavioral therapy.
If doxepin is prescribed, typical dosing ranges from 25-150 mg daily for anxiety, taken at bedtime due to its sedating effects. Lower doses (3-6 mg) are used for insomnia, as suggested by the American Academy of Sleep Medicine clinical practice guideline 1. Side effects include drowsiness, dry mouth, blurred vision, and constipation. Doxepin should be started at a low dose and gradually increased, and should not be stopped abruptly.
Treatment for hypervigilance is most effective when medication is combined with therapy addressing the underlying causes of the heightened alertness state. Doxepin works by increasing levels of norepinephrine and serotonin in the brain, which can help regulate mood and reduce anxiety symptoms that contribute to hypervigilance. However, the evidence for doxepin's efficacy in improving sleep maintenance is graded as weakly in favor, with minimal improvement in sleep latency but clinically significant improvements in wake after sleep onset, total sleep time, and sleep efficiency 1.
Key points to consider when prescribing doxepin for hypervigilance include:
- Starting with a low dose and gradually increasing as needed and tolerated
- Monitoring for side effects, such as drowsiness and dry mouth
- Combining medication with psychotherapy to address underlying causes of hypervigilance
- Considering alternative treatments, such as SSRIs, if doxepin is not effective or is not tolerated.
From the Research
Doxepin for Hypervigilance
- Doxepin is a tricyclic antidepressant that has been used to treat depression and anxiety, including hypervigilance 2.
- It has a sedative effect, which can be beneficial for patients with sleep disturbances and anxiety 2.
- In a study comparing doxepin to amoxapine, doxepin was found to cause more daytime drowsiness, which may be beneficial for patients with hypervigilance 3.
- Doxepin has been shown to be effective in treating depression with anxiety, including hypervigilance, although it may not be as effective as other treatments such as selective serotonin reuptake inhibitors (SSRIs) or cognitive behavioral therapy (CBT) 4, 5.
- The use of doxepin for hypervigilance may be limited by its side effects, including dry mouth, drowsiness, and constipation 2, 3, 5.
Comparison to Other Treatments
- Doxepin has been compared to other treatments such as amoxapine, mianserin, and SSRIs, and has been found to have similar efficacy, but with different side effect profiles 3, 5.
- The combination of an SSRI and CBT has been shown to be more effective than either treatment alone for depression and anxiety, including hypervigilance 4.
- Doxepin may be a useful treatment option for patients who do not respond to other treatments or who have contraindications to other medications 2, 5.