Vistaril vs. Xanax for anxiety – A Pharmacists perspective

Do you suffer from anxiety?

Have you tried different therapies with no luck?

Do anti-anxiety medications lead to adverse effects?

This post will compare hydroxyzine pamoate (Vistaril) with alprazolam (Xanax) in the treatment of anxiety.

Woman with anxiety

Anxiety

Did you know that anxiety disorders are the most prevalent mental health conditions and cause significant disability? According to the National Comorbidity Survey Replication (NCS-R), the lifetime prevalence of anxiety disorders in the United States is about 32%.

1

It is not surprising that anxiety disorders can lead to a loss of productivity greater than other mental health disorders. Even though there are many treatments for anxiety symptoms, only 60-85% of patients experience at least a 50% improvement in their symptoms using current medical and psychological treatments.2

Below are some symptoms of general anxiety3

  • Feeling restless, wound-up, or on-edge
  • Being easily fatigued
  • Having difficulty concentrating; mind going blank
  • Being irritable
  • Having muscle tension
  • Difficulty controlling feelings of worry
  • Having sleep problems, such as difficulty falling or staying asleep, restlessness, or unsatisfying sleep

The symptoms of panic disorder are listed below:

  • Heart palpitations, a pounding heartbeat, or an accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath, smothering or choking
  • Feelings of impending doom
  • Feelings of being out of control

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

Xanax picture

Alprazolam (XANAX) is a benzodiazepine used for the treatment of general anxiety disorder and panic attacks. In 2013, more than 48 alprazolam prescriptions were dispensed in the United States.4

Although alprazolam is an effective medication for treating anxiety, it does have some serious adverse effects. Some of the more significant unwanted side effects are listed below:

  • confusion
  • Problems speaking
  • poor balance or coordination
  • severe drowsiness
  • seizures
  • shortness of breath (respiratory depression)
  • Yellowing of the skin or eyes (jaundice)
  • severe skin rash

Alprazolam is also a controlled substance which means it has a high potential to be addictive. Therefore, other treatment options are preferred in those patients with a substance use disorder history.

The symptoms of withdrawal from alprazolam are as follows5

  • Sleep disturbances
  • Irritability
  • Increased tension and anxiety
  • panic attacks
  • hand tremor
  • sweating
  • Poor concentration
  • Dry heaves and nausea
  • Weight loss
  • Heart palpitations
  • Headache
  • Muscular Pain and stiffness
  • Seizures
  • Psychosis

Even those using alprazolam as an anxiety treatment may become psychologically and physically addicted. Since this drug decreases abnormal brain excitement and produces a calming effect, it has a high potential for misuse. It also has a swift onset of action and short duration, increasing its abuse potential and severity of withdrawal symptoms. Alprazolam’s severe withdrawal symptoms may be especially dangerous when abrupt discontinuation after long-term use.

As a medical professional, I only recommend alprazolam for the short-term treatment of severe anxiety.

Xanax has a black box warning for:

  • Risks from Concomitant Opioid Use – This combination may lead to profound sedation, difficulty breathing, coma, and even death.
  • Addiction, Abuse, and Misuse.
  • Dependence and withdrawal reactions.

I strongly suggest contacting a healthcare provider if you believe you are addicted to alprazolam or other medication.

One more interesting fact regarding alprazolam. This is one of the few drugs that I have heard patients complaining that the generic form does not work as well as the brand name. This may be an imagined phenomenon, but I have heard it from several patients.

Hydroxyzine pamoate is an antihistamine that non-selectively blocks peripheral and central histamine receptors. This medication can be used for medical conditions other than anxiety such as itching, nausea and vomiting, insomnia, and as a surgical adjunct.

As with any drug, Vistaril has side effects, some of which are listed below.

  • Dry mouth
  • Dizziness
  • Ataxia
  • Weakness
  • Slurred speech
  • Headache
  • Agitation
  • Nausea

More severe side effects of Vistaril include:

  • QT prolongation
  • torsades de pointes
  • Heatstroke
  • Seizures
  • Dyspnea
  • Hypersensitivity reactions

The recommended dose of Vistaril for anxiety in adults is 50-100mg by mouth every six hours as needed. Unlike Xanax, Vistaril is not a controlled substance but is a prescription medication. Hydroxyzine may interact with other anticholinergic agents, CNS depressants, and agents that prolong the QTc interval. Be sure to contact your doctor or pharmacist if you are taking other prescription medications before initiating Vistaril.

So which medication is a better choice for anxiety?

Both Xanax and Vistaril can help relieve the symptoms of anxiety. However, they both cause drowsiness and will interact with other CNS depressants, including ethanol. They are both prescription drugs, but Xanax is a controlled substance, so it is not suitable for those with a history of addictive behavior. In my professional opinion, Xanax is a better option for the short-term relief of severe anxiety and panic attacks. I believe it is more effective than hydroxyzine. Unfortunately, I was only able to find one study comparing the two agents in the setting of pre-anesthesia. This study came to the following conclusion:

“Alprazolam and hydroxyzine are both efficient and safe pre-anesthetic medications. However, a more pronounced, although modest, anxiolytics and the the absence of side effects favors the use of alprazolam over hydroxyzine.”6

Both alprazolam and hydroxyzine should be avoided during pregnancy. Xanax carries a possible risk of teratogenicity and risk of neonatal withdrawal symptoms, and floppy infant syndrome. Xanax is a better choice than hydroxyzine when breastfeeding, according to Epocrates (accessed 11/28/2021). Epocrates states, “May use low doses of alprazolam short-term with breastfeeding, otherwise monitor infant closely. There is a possible risk of CNS depression in the infant when the breastfeeding mother takes alprazolam.

Michael's Professional Opinion

Anxiety can be a debilitating condition and can lead to poor quality of life in some individuals. As with most diseases, there is a broad range of severity in the various anxiety disorders. My concern is that patients will go straight to their provider and end up with a prescription to treat their anxiety when a drug-free alternative may work just fine. In addition, there are non-drug options available for anxiety symptom relief.

Cognitive Behavioral Therapy (CBT)

One of the best treatments for anxiety is CBT. Cognitive Behavioral Therapy is the most researched form of psychotherapy in history. CBT is a psychological treatment that helps patients recognize thought patterns that are contributing to their anxiety. I believe we are all prone to thinking errors. Suppose we can learn to recognize these and train our minds to think differently. In that case, we can decrease our anxiety and depression symptoms without introducing chemicals into our bodies. The other problem is that when we become anxious, these thinking errors become distorted and amplified, leading to more anxiety.

I strongly suggest giving CBT a try before starting any anti-anxiety or antidepressant medication. The results will likely surprise you. If you don’t have the time to spend in therapy sessions, there is a book I recommend reading. I have included a link to this book below. I have read this book several times, and it has helped me deal with my thinking errors and helped many others do the same.

Lifestyle Changes

Smoking, drinking too much alcohol, eating the wrong types of foods, and not getting the proper amount of sleep can all make anxiety symptoms worse. Exercise can significantly help. Read my recent blog post on anxiety for more information on lifestyle changes.

Nutritional Supplements

As many of you know, I am the owner of Sunshine Nutraceuticals. I believe that natural supplements are a vital piece of the health and wellness puzzle. I also think that one of the possible uses of these supplements is to treat anxiety symptoms.

Prescription Drugs

If you are having a hard time coping with daily living or are considering hurting yourself, please call 911 and get help NOW. Regardless of how bad things seem, you can be helped. A person with a mental health disorder is no different than someone with heart disease, diabetes, or asthma; they just have a different organ of their body affected.

Back to our two drugs. Alprazolam should not be used for the long-term relief of anxiety. As mentioned earlier, it can be addictive and has a short duration of action. We often use a benzodiazepine such as alprazolam while waiting for the long-term anxiety medication to work. To treat anxiety, the drugs we start with are antidepressants, specifically selective serotonin reuptake inhibitors (SSRI’s). These medications often take several weeks to show maximum benefit, so it is critical to have a backup.

If you have any questions regarding this topic or any other subject, don’t hesitate to contact me by clicking the link in the author box below. Remember to take care of your mind and body always!  

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

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