What is the recommended dosage and potential side effects of using Atarax (hydroxyzine) and Lexapro (escitalopram) in patients with anxiety and depression?

Use of Atarax (Hydroxyzine) and Lexapro (Escitalopram) for Anxiety and Depression

For patients with comorbid anxiety and depression, Lexapro (escitalopram) should be the primary treatment, starting at 10 mg once daily, with Atarax (hydroxyzine) reserved only for short-term adjunctive use during the initial weeks if severe anxiety symptoms require immediate relief. 1

Primary Treatment: Lexapro (Escitalopram)

Dosing Recommendations

Escitalopram is the preferred first-line agent for treating both depression and anxiety disorders, with a recommended starting dose of 10 mg once daily, taken in the morning or evening with or without food. 1

• Initial dosing: Start at 10 mg daily for both major depressive disorder and generalized anxiety disorder 1
• Dose escalation: If needed, increase to 20 mg daily after a minimum of one week for adults with GAD, or after three weeks for adolescents with depression 1
• Special populations: Elderly patients and those with hepatic impairment should receive 10 mg/day as the maximum dose 1

Efficacy Profile

Escitalopram demonstrates superior efficacy compared to placebo and comparable or superior efficacy to other SSRIs for treating both depression and anxiety symptoms. 2, 3

• Escitalopram shows significant improvement in anxiety symptoms as early as the first week of treatment (p<0.05), with more pronounced effects by week two (p<0.001) 4
• The medication is effective for generalized anxiety disorder, panic disorder, social phobia, and obsessive-compulsive disorder 5
• Long-term administration demonstrates preventive effects on depression relapse and recurrence 3

Side Effects and Safety

Common adverse effects include nausea (15%), insomnia (9%), ejaculation disorder (9% in males), diarrhea (8%), and fatigue (5%), though these are generally mild and transient. 1

• Discontinuation rates: Only 6% of patients discontinued due to adverse events in depression trials, compared to 2% with placebo 1
• Cardiovascular considerations: Citalopram/escitalopram have lower QTc prolongation risk than citalopram alone, though caution is warranted at doses exceeding 40 mg/day 2
• Drug interactions: Escitalopram has minimal effect on CYP450 isoenzymes compared to other SSRIs, resulting in lower propensity for drug interactions 2

Adjunctive Use: Atarax (Hydroxyzine)

Limited Role in Treatment

Hydroxyzine should only be considered for short-term adjunctive use during the initial 2-4 weeks of SSRI therapy when immediate anxiety relief is needed, as it does not address the underlying depression. 6, 7

• Hydroxyzine demonstrated superiority over placebo for GAD (OR 0.30,95% CI 0.15 to 0.58) but with high risk of bias in available studies 7
• In a clinical trial of 50 patients with generalized anxiety, 66% showed excellent or good results, though 36% experienced transitory sleepiness 6

Dosing and Side Effects

When used, hydroxyzine typically causes significant sedation (36% of patients) and weakness (18%), limiting its utility for long-term management. 6

• Common adverse effects include drowsiness, weakness (18%), headache (6%), appetite changes (6%), and dry mucosa (2%) 6
• The medication was equivalent to benzodiazepines and buspirone in efficacy but associated with higher rates of sleepiness/drowsiness (OR 1.74,95% CI 0.86 to 3.53) 7

Critical Safety Considerations

Serotonin Syndrome Risk

When combining any medications, monitor for serotonin syndrome, which can manifest within 24-48 hours with mental status changes, neuromuscular hyperactivity, and autonomic instability. 2

• Avoid combining escitalopram with MAOIs (require 14-day washout period) 1
• Exercise caution when combining with tramadol, dextromethorphan, or other serotonergic agents 2

Discontinuation Management

Gradual dose reduction is essential when discontinuing escitalopram to minimize withdrawal symptoms including dizziness, fatigue, nausea, and sensory disturbances. 2, 1

• Escitalopram has milder discontinuation symptoms compared to paroxetine 3
• If intolerable symptoms occur, resume the previous dose and taper more gradually 1

Monitoring Requirements

Screen all patients for bipolar disorder history before initiating escitalopram, as antidepressants can precipitate manic episodes. 1

• Monitor for treatment response using standardized symptom rating scales 2
• Reassess periodically for continued need for maintenance treatment 1
• Full therapeutic trial requires 4-8 weeks, with at least 2 weeks at maximum tolerated dose 2

Clinical Algorithm

The optimal approach prioritizes escitalopram monotherapy, reserving hydroxyzine only for bridging severe acute anxiety during SSRI initiation:

1. Start escitalopram 10 mg daily 1
2. If severe anxiety requires immediate relief during weeks 1-2, consider hydroxyzine as needed (not scheduled) 6, 7
3. Discontinue hydroxyzine by week 3-4 as escitalopram's anxiolytic effects emerge 4
4. Increase escitalopram to 20 mg after week 1-3 if inadequate response 1
5. Continue for minimum 4-8 weeks before assessing full efficacy 2