Hydroxyzine is Not Helping the Anxiety
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Q:  My doc gave hydroxyzine for anxiety and it does not do it is there better meds for that? I am on lactimal  and seroquel 25 for sleep. thx


Dear Fran --

Of course, the first thing one would want to know is where that anxiety is coming from.  Sometimes, anxiety can be a bipolar symptom.  This is not widely recognized.  It is somewhat controversial.  You can read more about this (probably more than you want to know) on my website page about Anxiety As a Bipolar Symptom. 

If your anxiety is indeed a symptom that is coming from the bipolar disorder, it would tend to be "cyclic": clearly worse on some days than on others, for no clear reason. (This does not clearly established it as "bipolar", however). In that case, any medication that decreases cycling can help.  This opens the entire array of mood stabilizers as options (including turning up those you are currently taking, but you should definitely not do that on your own; occasionally lamotrigine can make anxiety worse as the dose goes up, for example; and Seroquel requires close monitoring including laboratory testing). 

If your anxiety is not clearly "cyclic", it might still be associated with your bipolar disorder (presuming that is what you have, and that it is an accurate diagnosis).  Sometimes people have continuous "mixed states" that don't really "cycle", but can still be "bipolar".  (The reason for all the quotation marks is that all of these terms are awkward, sometimes inaccurate or misleading, and many of them either a controversial or hard to really pin down.  So everything has to be taken with a big grain of salt).  You can read more about that on my page about mixed states as "waves". 

In the case of anxiety that is not clearly "cyclic", but is still presumably coming from bipolar disorder (and not some additional potential source, such as life circumstances; or an independent anxiety condition such as Posttraumatic Stress Disorder, a very common code traveler with bipolar disorder), would still turn to any of the mood stabilizer options.   

Next, if none of those explanations seemed to make sense for you, as you discussed it with your psychiatrist, you'd want to examine the other potential sources of anxiety.  Other anxiety disorders to be considered are listed on that first webpage listed above, each with some thoughts about how to handle them if they are co-occurring with bipolar disorder. 

After all that, you and your psychiatrist could end up discussing "treating the symptom".  Hydroxyzine probably fits there.  Alternatives include the "benzodiazepine" family, including Valium and its many cousins.  Among them we tend to use lorazepam and clonazapam (Ativan and Klonopin respectively).   

Some people seem to respond to another anti-anxiety medication called buspirone (BuSpar), although this is not very commonly used in psychiatry, as it seems that most colleagues share my experience with it: it just does not seem to have much clout. 

For some people with severe anxiety in the context of bipolar disorder, just getting better sleep can make quite a difference.  I have a lengthy discussion of sleep in the context of light and darkness that might be of interest in this respect. 

Finally, as your psychiatrist has probably discussed with you, higher doses of Seroquel are commonly used to treat anxiety.  The company that makes it has applied to the FDA for an "indication" for the treatment of "generalized anxiety disorder".  That means they have data showing that the medication works for the treatment of that kind of anxiety.  Unfortunately, it also appears that higher doses of Seroquel have more potential for causing weight gain and increases in glucose, so these require consistent monitoring when taking that medication (in any dose). 

I hope that something in that collection proves to be useful to you and your psychiatrist as you address this problem.

Dr. Phelps

Published May, 2008


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